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COLLEGE  OF  PHYSIC!  INS 
AND   SURGEONS 


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STREET  RAILWAY  ACCIDENTS 


COMPILED  FOR  THE  USE  OF 
THE  TRIAL   DEPARTMENT 


OF 


THE  NEW  YORK  CITY  RAILWAY  COMPANY 


BY 


JOHN  J.  MOORHEAD,  M.  D. 

Chief  Surgeon 


Entered  according  to  Act  of  Congress,  in  the 

year  1906,  by  j.  j.  m.,  in  the  office 

of  Librarian    of    Congress, 

at  Washington. 


John  C.  Rankin  Co.,  Printers,  54  &  56  Dey  St.,  New  York. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/streetrailwayaccOOmoor 


AUTHORITIES. 

American  Text  Book  of  Surgery. 

Von    Bergman's    "System    of    Surgery"     (Translated 
by  Bull). 

Woolsey's  "Applied  Surgical  Anatomy." 
Phelp's  "Traumatic  Injuries  of  the  Brain." 
JStimson's  "Fractures  and  Dislocations." 
Scudder's  "Treatment  of  Fractures." 
Edgar's  "Obstetrics." 
American  Text  Book  of  Gynecology. 
Dudley's  "Gynecology." 

Church  and  Peterson's  "Mental  and  Nervous  Diseases." 
Gowers'  "Diseases  of  the  Nervous  System." 
Osier's  "Practice  of  Medicine." 
Reference  Handbook  of  Medical  Sciences. 


PREFACE. 

These  monographs  respecting  diverse  surgical  ailments  are 
the  outgrowth  of  requests  from  the  Trial  Counsel  for  infor- 
mation on  respective  subjects.  It  was  finally  deemed  advis- 
able to  anticipate  such  demands  by  furnishing  articles  on  the 
more  common  injuries  alleged,  and  these  took  the  form  of 
manifolded  typewritten  brochures.  The  list  has  now  grown 
large  enough  to  warrant  publication  in  the  present  form,  and 
in  offering  the  following  pages,  no  attempt  has  been  made  to 
exhaustively  treat  any  given  topic,  the  aim  being  to  furnish 
the  necessary  working  knowledge  for  Trial  purposes ;  and  to 
give  enough  technical  explanation  to  understandingly  consult 
recognized  quoted  or  mentioned  standard  authorities. 

There  has  constantly  been  in  mind  the  description  of  the 
average  and  usual,  rather  than  the  exceptional  or  unusual 
case,  and  careful  mention  has  been  made  of  the  elements 
liable  to  modify  the  causation  or  outcome  of  a  given  injury. 
The  diagrams  used  were  obtained  through  the  courtesy  of 
the  medical  publishers,  W.  B.  Saunders  Company,  of  Phila- 
delphia. 

Oct.,  1906.  J.  J.  M. 


INDEX. 

Page 

1.  Wounds    8 

2.  Contusions 10 

3.  Sprains,  Strains  and  Ruptured  Ligaments 12 

4.  Shock  14 

5.  Synovitis  16 

6.  Varicose  Veins    19 

7.  Fractures   23 

8.  Fracture  of  Clavicle 28 

9.  Fracture  of  Humerus 32 

10.  Colles'  Fracture 37 

1 1 .  Fracture  of  Ribs 44 

12.  Fracture  of  Neck  of  Femur 52 

13.  Fracture  of  Patella 60 

14.  Pott's  Fracture 65 

15.  Fracture  of  the  Skull 70 

16.  Dislocations    80 

17.  Stiff   Joints 83 

18.  Herniae   92 

19.  Uterine  Trouble 100 

20.  Movable  Kidney 107 

21.  Concussion  of  Brain 113 

22.  Neurasthenia 117 

23.  Affections  of  Coccyx 126 

24.  Electric  Shock 133 

25.  X-Rays   139 

26.  Abortions  and  Miscarriages 145 


GENERAL  REMARKS. 

The  physical  evidences  of  anv  injury  manifest  themselves 
by: 

(A)     Objective  and  (B)  Subjective  symptoms. 

(A)  Objective  Symptoms  are  those  which  are  apparent 
to  the  observer;  they  can  be  seen  or  felt,  or  otherwise  become 
manifest  to  the  senses. 

(B)  Subjective  Symptoms  are  those  which  are  unappar- 
ent  to  the  observer  and  are  complained  of  by  the  patient;  they 
are  invisible  and  impalpable. 

A  Subjective  Symptom  can  often  be  made  Objective; 
as,  for  example,  genuine  pain  can  be  elicited  by  the  uniform 
complaint  of  the  sufferer,  if  an  exclamation  be  made  each 
time  the  alleged  sensitive  place  be  touched.  Likewise,  if  pres- 
sure over  a  painful  area  accelerates  the  pulse-rate,  then  pain 
becomes  objectively  manifest — this  test  is  referred  to  as 
"Mannkopf's  Sign,"  and  has  considerable  corroborative  value. 

A  complete  examination  of  the  injured  is  comprehended  by 
the  following  six  methods: 

(i)     Inspection;  (4)     Auscultation; 

(2)  Palpation;  (5)     Mensuration; 

(3)  Percussion ;  (6)     Motion. 

(1)  Inspection  determines  the  site,  type,  degree  and  sur- 
face extent  of  the  injury;  for  example,  a  broken  limb 
would  be  located  in  a  given  site,  it  would  be  of  a  certain 
type,  and  of  moderate  or  severe  degree.  Whatever  can 
be  seen  by  the  eye  is  noted  under  the  head  of  Inspec- 
tion. 

(2)  Palpation  determines  the  nature  of  the  injury  as  man- 
ifested to  the  sense  of  touch;  the  broken  limb  would 
give  the  characteristic  "crepitus"  (grating  sound)  and 
the  "abnormal  mobility"  and  other  corroborative  indi- 
cations. Whatever  can  be  felt  (either  by  the  hands 
or  apparatus)  is  noted  under  the  heading  of  Palpation. 

(3)  Percussion  refers  to  the  information  elicited  by  tap- 
ping (with  the  fingers     or  special  instrument)   the  in- 


jured  part;  a  broken  rib  might  thus  be  shown  to  have 
a  blood  collection  in  the  chest  as  indicated  by  the  dull 
sound  and  feel  when  the  part  was  "tapped"  upon. 

(4)  Auscultation  means  the  confirmation  obtained  by- 
listening  over  an  injured  part,  either  with  the  ear  or 
an  instrument  ("Stethoscope").  A  broken  rib  could 
be  heard  to  crepitate  (grating  or  "clicking"  sound),  or 
the  breathing  might  be  found  to  be  more  or  less  affect- 
ed. 

(5)  Mensuration  determines  the  magnitude  of  the  injury 
in  terms  of  inches  or  centimeters. 

(6)  Motion  becomes  manifest  either  by : 

(a)  Active,  or 

(b)  Passive  means. 

Active  Motion  means  the  patient's  voluntary  ability  to 

functionate  an  injured  part,  and  Passive  Motion  refers 

tew  the  motion  obtained  by  the  examiner's  efforts ;  for 

example,   by  Active   Motion,   a  person   could   move   a 

stiff  shoulder  to  a  right  angle,  but,  by  Passive  Motion, 

the  examiner  could  put  the  part  through  the  normal 

movement-range. 

It  can  hence  be  seen  that  Inspection  appeals  to  the  sense  of 

Sight;  Palpation  or  Percussion  to  the  sense  of  Touch;  and 

Auscultation  to  the  sense  of  Hearing. 

Manifestations  obtained  by  the  aid  of  the  Microscope, 
Chemical  Analysis,  Electrical  Apparatus,  X-rays,  Blood  Ex- 
amination, or  other  diagnostic  means,  are  generally  cumula- 
tive rather  than  essential,  and  the  ordinary  injury  can  be 
sufficiently  comprehended  by  the  six  standard  methods  men- 
tioned. 

The  essential  in  any  examination  is  the  capacity  to  ac- 
curately determine  the  self-propounded  question  regarding 
every  injured-site;  viz.:  What  does  it  look  like,  and  how  does 
it  act? 


I.     WOUNDS 


CLASSES:    All  are  divided  into  four  classes 
i.     Incised. 


Lacerated. 

Contused. 

Punctured. 


4- 

An  incised  wound  is  one  in  which  the  edges  are  clean 
cut,  such  as  that  made  by  a  knife  or  glass. 

A  lacerated  wound  is  one  in  which  the  edges  are 
ragged  and  irregular. 

A  contused  wound  is  one  in  which  the  edges  are 
ragged  and  bruised  and  more  or  less  dented. 

A  punctured  wound  is  one  in  which  a  punched-out 
appearance  is  presented,  usually  with  loss  of  skin  or 
tissue. 

SYMPTOMS:  All  wounds  have  the  following  in  common: 
Bleeding,  gaping  edges,  swelling,  pain,  inconvenience 
or  disability. 

HEALING:  This  depends  upon  the  type  of  the  wound,  its 
location,  the  treatment,  and  the  individual. 

INCISED  wounds  heal  promptly  in  from 
three  to  ten  days,  and  usually  leave  a  thin, 
more  or  less  noticeable  scar. 

LACERATED,  CONTUSED  and  PUNC- 
TURED wounds  heal  more  slowly,  and  are 
usually  attended  with  the  presence  of  pus 
and  some  inflammation  due  to  dirt  or  for- 
eign germ-containing  matter.  They  com- 
monly heal  in  from  one  to  three  weeks, 
and  the  scar  is  irregular,  thick  and  often- 
times raised  or  puckered. 


All  healing  is  by: 

A.  First  Intention; 

B.  Second  Intention ; 

C.  Granulation. 

FIRST  INTENTION  HEALING  (also 
known  as  "Primary  Union")  is  where 
the  edges  of  the  wound  coapt  and  heal 
kindly  without  the  presence  of  pus ; 
most  incised  wounds  heal  in  this 
manner. 

SECOND  INTENTION  HEALING  (also 
known  as  "Secondary  Union")  is 
where  the  edges  do  not  freely  unite 
and  new  tissue  springs  up  from  the 
sides  and  bottom  of  the  wound,  pus 
usually  being  present;  most  lacerated 
wounds  heal  in  this  manner. 

GRANULATION  HEALING  is  where 
an  excessive  amount  of  new  tissue 
forms  from  the  bottom  of  the  wound 
(this  being  called  scar  or  granulation 
tissue),  and  it  later  contracts  and 
causes  an  irregular  and  ugly  raised 
scar ;  it  follows  severe  lacerated  and 
punctured  wounds. 

TREATMENT:     This  can  be  summed  up  under  the  three 
headings  of: 

A.  Bringing  the  wound  edges  together  by 
stitches  or  adhesive  plaster  or  bandages ; 

B.  The  application  of  apparatus  such  as 
bandages  or  splints  to  keep  the  parts  at 
rest; 

C.  The  use  of  antiseptics  to  prevent  blood 
poisoning. 


II.     CONTUSIONS 


A  contusion  is  commonly  known  as  a  bruise  or  "black  and 
blue"  spot,  and  is  the  result  of  violence  inflicted  upon  the  skin 
or  subcutaneous  tissue;  technically  it  is  the  subcutaneous 
rupture  of  small  blood  vessels,  usually  capillaries  or  veins. 

SYMPTOMS:  The  average  contusion  at  first  shows  nothing 
but  a  red  or  slightly  puffed  spot  where  the  violence 
has  been  inflicted,  but  within  a  short  time — usually 
within  24  hours — this  spot  becomes  more  or  less  swol- 
len, dusky  or  blue;  if  it  extends  over  a  large  area  and 
gives  a  more  or  less  mottled  appearance,  then  the  term 
ECCHYMOSIS  is  given  to  it,  this  meaning  a  diffuse 
area  of  discoloration  (the  best  example  of  this  is  a 
"black  eye").  With  the  above,  there  is  more  or  less 
swelling,  pain  and  disturbance  of  function.  Later  on 
the  blue  color  gives  place  to  a  lighter  shade,  and 
finally  becomes  decolorized  and  a  yellow  mark  re- 
mains; this  in  turn  finally  gives  place  to  the  normal 
appearance,  all  depending  upon  the  severity  of  the 
contusion  and  the  activity  of  the  adjacent  blood  ves- 
sels. The  better  supplied  the  involved  part  is  with 
blood,  the  more  rapid  will  be  the  absorption  of  the 
blood  that  has  been  thrown  out. 

If  the  contusion  be  DEEP  SEATED  and  sharply 
localized,  it  is  of  a  severer  type  and  then  shows  itself 
as  a  decided,  usually  more  or  less  egg-shaped  swelling, 
and  is  referred  to  as  a  HEMATOMA — this  liter- 
ally meaning  a  Blood  Tumor  or  "Blood  Blister." 

No  contusion  ever  becomes  darkly  discolored  until 
some  hours  have  elapsed,  and  the  early  onset  of  "black 
and  blue"  marks  usually  denotes  a  mild,  superficial 
bruise. 

COURSE  AND  DURATION:  A  mild  contusion  is  of  no 
consequence  and  causes  no  disability;  if  it  be  severe, 

10 


it  may  cause  partial  or  complete  disability;  but,  in  a 
general  way,  no  contusion  ought  to  disable  for  a 
longer  period  than  ten  days  or  two  weeks.  A  con- 
tusion of  the  parts  about  the  hip  is  frequently  severe 
enough  to  cause  considerable  disability,  this  being  the 
main  exception. 

TREATMENT:  This  can  be  summed  up  under  the  head  of 
rest  and  external  soothing  applications,  usually  in  the 
form  of  liniments. 

If  a  HEMATOMA  be  present,  or  if  the  blood  is  not 
readily  absorbed  by  other  means,  a  hypodermic  needle 
is  frequently  introduced  and  the  more  or  less  clotted 
blood  is  drawn  off*.  This  is  a  rapid,  safe,  sure  and 
modern  method. 


11 


III.      SPRAINS,    STRAINS,    AND    RUPTURED    LIGA- 
MENTS. 


A  SPRAIN  is  the  sudden  stretching  or  wrenching  of  the 
ligaments  or  muscles  of  a  part  with  a  tearing  of  some  of  the 
finer  fibres  of  the  same. 

A  STRAIN  or  WRENCH  is  the  sudden  stretching  of  the 
ligaments  or  muscles  of  a  part  without  rupture  of  any  of  the 
fibres. 

A  RUPTURED  LIGAMENT,  or  A  RUPTURED 
MUSCLE — as  the  name  implies — is  the  severing,  more  or  less 
completely,  of  the  ligaments  or  muscles  of  the  part  involved. 

CAUSE:  ALWAYS  due  to  violence,  either  direct,  or  indirect; 
and  each  also  occurs  as  an  accompaniment  of  a  dislo- 
cation and  fracture. 

SYMPTOMS:  These  can  be  summed  up  under  the  headings  of 
Pain, 
Swelling, 
Diminution  of  Function. 

COURSE  AND  DURATION:  A  STRAIN  is  rarely  dis- 
abling, but  causes  more  or  less  lameness  and  discom- 
fort for  a  short  time  only. 

A  SPRAIN,  especially  if  it  be  of  an  ankle,  often- 
times disables  for  from  ten  days  to  four  weeks. 

A  RUPTURED  LIGAMENT  will  frequently  dis- 
able from  three  weeks  to  six  weeks. 

SPRAINS  and  RUPTURED  LIGAMENTS  usually 
heal  completely  without  leaving  permanent  defects; 
but  in  rheumatics  and  in  the  aged  the  tendency  to  re- 
currence is  liable,  and  oftentimes  a  persistently  swollen 
and  somewhat  disabled  joint  remains. 


12 


TREATMENT:  This  consists  in  placing  the  part  at  rest 
cither  by  splints,  bandages,  or  adhesive  plaster;  and 
the  application  of  liniments,  or  ointments,  or  iodine, 
as  counter-irritants. 

Later,  the  part  is  massaged  and  used;  and,  in  fact, 
the  most  modern  surgeons  encourage  early  action  of 
the  joint.  In  certain  joints,  notably  the  ankle,  the  "Ad- 
hesive Plaster  Strapping"  method  of  treatment  is  the 
standard  hospital  procedure,  and  with  this  application 
a  swollen  and  disabled  joint  is  promptly  reduced  and 
function  is  most  speedily  restored.  Strips  of  one  inch 
wide  adhesive  (or  "sticking")  plaster  are  wound  in  a 
somewhat  "figure  of  8"  manner  about  the  swollen  joint, 
completely  encircling  it  snugly.  The  scheme  was  de- 
vised byDr.  Gibney,  and  is  often  referred  to  as  "Gib- 
ney's  Basket  Weave  Dressing." 


13 


IV.     SHOCK. 


SHOCK  is  a  general  term  which  commonly  means  a 
TRANSITORY  DEPRESSION  OF  THE  VITAL  FORCES, 
especially  those  connected  with  the  HEART  and  the 
NERVOUS  SYSTEM. 

CAUSES:  It  is  a  constant  accompaniment  of  any  injury,  and 
is  present  to  a  greater  or  lesser  degree  following 
every  sort  of  violence. 

DEGREE:  SHOCK  is  of  varying  degrees,  and  is  usually 
classified  as  MILD,  MODERATE,  and  SEVERE; 
and  which  degree  prevails  dependent  largely  upon  the 
type  of  the  violence  and  its  duration,  but  mainly  upon 
the  individual. 

Women  stand  shock  very  much  better  than  men. 
Those  of  a  happy,  sanguine  temperament  are  less 
affected  than  those  of  opposite  disposition. 

Young  people  react  from  it  better  than  the  aged ;  and 
those  who  are  accustomed  to  an  out-of-door  occupa- 
tion are  less  affected  than  those  of  sedentary  habits. 

SYMPTOMS:  Depend  upon  the  degree  of  the  shock  and 
the  producing  cause. 

In  the  MILD  form  there  is  a  sudden  giddiness  and 
pallor,  but  the  effects  are  slight  and  like  a  mild  "faint- 
ing spell." 

In  the  MODERATE  form  of  shock,  the  individual 
is  more  or  less  dazed  or  stunned,  the  face  is  blanched, 
the  circulation  is  depressed  so  that  the  pulse  is  slow 
and  weak — or  very  rapid — and  oftentimes  there  is 
vomiting;  but  the  individual  very  readily  regains  his 
senses  and  his  normal  appearance. 

14 


In  the  SEVERE  grades  of  shock  the  individual  is 
usually  unconscious;  very  pale;  skin  is  cold  and 
clammy;  pulse  is  slow — or  very  rapid — and  weak;  he 
nearly  always  vomits  and  not  infrequently  passes 
faeces  and  urine  involuntarily;  in  a  word,  he  is  in  a 
state  of  profound  collapse.  This  is  a  very  serious 
condition  to  deal  with,  but  is  not  often  met  unless  in 
grave  injuries.  An  individual  in  this  condition  may 
die  within  an  hour,  or  may  remain  24  hours  in  a 
semi-comatose  state  and  very  slowly  regain  his  normal 
condition. 

A  main  characteristic  of  shock  is  the  fact  that  it 
occurs  immediately  upon  receipt  of  the  violence,  and, 
if  it  is  postponed,  it  is  not  due  to  the  violence  directly, 
but  to  some  intervening  cause,  or  to  something  com- 
plicating the  violence;  for  example:  if  a  person 
receives  a  blow  on  the  abdomen,  he  may  walk  and  give 
no  evidence  of  having  been  injured,  but  within  an 
hour  or  two  he  may  go  into  a  state  of  shock  and 
collapse  and  then  be  found  to  have  internal  hemorrhage 
—but  he  would  still  be  said  to  suffer  from  "SHOCK." 

It  is  also  true  that  when  shock  is  recovered  from, 
the  individual  is  very  rarely  liable  to  recurrence ;  but 
when  it  does  recur  it  almost  always  indicates  bleeding, 
and  is  then  referred  to  as  "SECONDARY  SHOCK." 

TREATMENT:    This  can  be  summed  up  under  the  head- 
ings of: 

Stimulation;  as  by  heart  tonics  like  whiskey, 

digitalis  or  strychnine; 
Rest  and 
Hot  Applications;  such  as  hot  water  bags  or 

hot  water  bottles. 


IS 


V.     SYNOVITIS 


This  is  a  general  term  which  means  the  inflammation  of  the 
lining  membrane  of  any  joint,  this  membrane  being  known  as 
the  SYNOVIAL  MEMBRANE.  Because  of  the  frequency  of 
synovitis  in  the  KNEE,  when  the  term  SYNOVITIS  is  used, 
it  usually  refers  to  this  ailment  affecting  this  joint,  and  is  com- 
monly known  then  as  "water  on  the  knee." 

ANATOMY:  This  SYNOVIAL  MEMBRANE  is  a  shiny, 
tissue-paper-like,  fibrous  substance  lining  the  interior 
of  every  joint,  and  which  secretes  a  fluid  known  as 
the  SYNOVIAL  FLUID  to  act  as  lubricant  for  the 
joint.  When  this  membrane  is  irritated,  as  by  out- 
side violence,  it  becomes  inflammed  and  the  normal 
synovial  fluid  is  increased,  and  hence  fluid  accumulates 
in  the  joint  to  a  greater  or  less  degree,  producing 
SYNOVITIS. 

CAUSES:  Injury  is  a  very  common  cause,  and  can  be  in- 
flicted directly  over  the  joint  or  at  a  distance  from  the 
joint.  It  is  a  usual  accompaniment  of  sprains,  con- 
tusions of  a  joint,  dislocations  and  fractures  at  or  about 
the  junction  of  a  joint;  other  common  causes  are  cold, 
rheumatism,  and  the  presence  of  floating  cartilages,  due 
to  prior  injury.  It  is  also  present  in  cases  of  joint 
tuberculosis. 

VARIETIES:  It  occurs  in  two  forms,  either  ACUTE  or 
CHRONIC. 

In  the  ACLTTE  form  it  follows  soon  after  the  re- 
ceipt of  violence  (or  other  producing  cause),  and  the 
joint  becomes  rapidly  swollen,  painful,  and  more  or 
less  disabled. 

The  CHRONIC  form  is  a  progression  of  the  acute, 
and  the  joint  is  still  swollen,  but  is  less  painful,  but  i9 
more  or  less  disabled. 

16 


SYMPTOMS:  In  a  general  way,  every  case  of  synovitis 
shows  swelling  of  the  joint  because  of  the  excess  of 
fluid  in  it,  and  more  or  less  rounded  outline  of  the  part; 
pain;  and  limitation  of  the  movement  of  the  joint, 
with  stiffness  of  greater  or  lesser  degree. 

DURATION:  ACUTE  SYNOVITIS  lasts— depending  upon 
its  severity  and  location — from  two  to  six  weeks. 

CHRONIC  SYNOVITIS  lasts  from  six  weeks  to 
many  months,  and  is  not  infrequently  to  some  extent 
permanent,  especially  when  neglected  or  improperly 
treated. 


TREATMENT:  In  the  ACUTE  form  this  can  be  summed 
up  under  the  head  of  rest  and  immobilization.  The 
joint  is  kept  quiet,  ice-bags  or  other  applications  (such 
as  lead  and  opium  wash)  are  placed  about  the  part  and 
a  firm  bandage  or  splint  applied,  these  being  frequently 
changed,  so  that  constant  pressure  is  made  to  reduce 
the  amount  of  the  fluid.  Some  surgeons  introduce  a 
needle  into  the  joint  and  draw  off  the  fluid,  if  the  above 
means  do  not  show  rapid  tendency  towards  cure. 

In  the  CHRONIC  form,  treatment  is  moderate 
motion,  massage  and  electricity;  and  if  the  joint  has 
assumed  a  position  of  stiffness  so  that  it  can  only  be 
bent  part  way  (technically  known  as  ANCHYLOSIS), 
then  the  part  is  more  forcibly  moved  so  as  to  break 
up  the  bands  of  fibre  which  have  formed  across  the  joint 
(technically  known  as  ADHESIONS),  and  this  not 
infrequently  requires  the  use  of  an  anaesthetic.  Var- 
ious external  applications,  usually  irritating  ointments 
and  iodine,  are  often  employed  to  hasten  the  absorp- 
tion of  the  fluid,  all  of  them  acting  as  counter-irritants. 

17 


PROGNOSIS:  There  is  sometimes  a  tendency  for  recurrence 
of  synovitis  in  either  of  its  two  forms,  and  it  is  especi- 
ally liable  to  reappear  in  those  of  rheumatic  tendency, 
or  in  those  who  have  laborious  occupation,  especially 
such  as  requires  much  bending  of  the  joint  affected,  and 
in  instances  where  ordinary  precautions  are  neglected. 


18 


VI.     VARICOSE     VEINS. 


A  Varicose  vein  is  an  enlarged,  dilated,  and  more  or  less 
visible  vein,  or  usually  a  set  of  veins ;  and  because  varicose 
veins  occur  most  commonly  in  the  leg,  when  the  term  is  used, 
this  location  of  the  body  is  usually  inferred. 

They  are  commonest  in  the  lower  extremity  because  this 
portion  of  the  body  is  furthest  away  from  the  heart  (the  pump- 
ing center)  and  hence  the  blood  in  the  veins  remains  in  this 
locality  owing  to  gravity  and  posture. 

ANATOMY:  Veins  are  elastic  tubes  which  are  made  up  of 
three  coats,  and  the  circulation  in  a  vein  is  toward  the 
heart,  being  just  the  opposite  of  circulation  in  the 
arteries,  which  is  away  from  the  heart. 

All  veins,  especially  the  larger  veins,  are  provided 
with  valves  made  up  of  two  segments  which  point 
toward  the  heart;  and  when  veins  become  varicose, 
they  lose  their  elasticity,  and  hence  the  valves  do  not 
properly  close  and  more  blood  remains  in  a  vessel  than 
it  is  intended  to  hold,  and  soon  it  permanently  expands ; 
it  is  precisely  as  if  a  rubber  tube  were  many  times  over- 
distended  and  finally  became  rigid  and  brittle. 

All  varicose  veins  are  enlarged,  visible  and  some- 
what painful,  mainly  because  of  the  fact  that  the  blood 
remains  in  the  extremity  and  causes  more  or  less  en- 
largement of  the  limb,  and  this  in  turn  produces 
pressure  on  the  sensitive  nerves. 

In  old  people  especially,  there  is  the  liability  of  what 
are  technically  known  as  VARICOSE  ULCERS,  this 
referring  to  a  wound  of  ulcer-like  form  that  occurs 
around  about  a  mass  of  dilated  veins,  and  usually  re- 
sults from  slight  injury;  as,  for  example,  a  scrape  of 
the  shin  will  very  frequently  result  in  a  varicose  ulcer 
because  of  the  fact  that  the  circulation  is  inactive  and 

19 


the  healing  process  is  therefore  diminished.  These 
ulcers  are  healed  with  great  difficulty,  and  they  often 
last  for  years.  Cases  of  this  sort  form  a  very  large  per- 
centage of  all  dispensary  practice. 

CAUSATION:  There  is  nothing  physiological  as  to  the  oc- 
currence of  this  condition  and  the  sole  productive  factor 
is  long  continued  abnormal  obstruction  to  the  passage 
of  a  fluid  in  an  elastic  tube ;  in  other  words,  the  fluid 
contents  of  the  veins  are  "dammed  back,"  the  veins 
hence  increase  their  calibre,  and  in  time  remain  so  per- 
manently, because  they  have  lost  by  over-distention 
their  power  of  contractility. 

An  arbitrary  classification    would    denominate    the 
causes  as : 

(a)  Superficial  Causes 

(b)  Deep  Causes 

(a)  Superficial  Causes: 

Tight  lacing.       Prolonged  standing. 

Tight  garters.      Occupation  causing  legs  to  dangle. 

Obesity. 

(b)  Deep  Causes: 

Poor  pumping  action  on  part  of  the  heart  and  conse- 
quent inability  to  push  the  blood  fast  enough  out  of  the 
veins,  and  they  hence  increase  in  size;  this  may  occur 
(and  often  does)  in: 

Heart  Disease;  Kidney  Disease  (Bright's  Dis- 
ease) ;  Liver  Disease  (Cirrhosis)  ;  Disease 
of  Arteries  (Arterio  Sclerosis)  ;  and  in  any 
ailment  in  which  poor  circulation  is  a 
factor. 
Pressure  over  a  main  trunk  of  a  vein  is  a  fre- 
quent factor,  especially  in  the  lower  ex- 
tremities, and  this  may  be  due  to:  Preg- 
nancy where  the  child's  body  bulges  the 
lower  abdomen   (pelvis)  ;  or  Constipation 

20 


resulting  in  straining  and  engorgement  of 
the  lower  bowel  (rectum)  ;  or  to  Tumors 
pressing  upon  the  veins  that  empty  the 
extremities. 

Some  persons  are  born  with  veins  that 
are  incapable  of  standing  the  necessary 
pressure  and  they  soon  permanently  dilate  ; 
Prof.  Osier  refers  to  such  vessels  as  lack- 
ing in  "Vital  Rubber." 

Aged  Persons,  or  those  who  have  worked  hard, 
for  this  same  reason  are  more  prone  to  this 
ailment  owing  to  the  strain  and  stress 
incident  to  years  of  service. 

Structurally,  dilated  veins  are  more  common  on 
the  left  side  because  the  blood  vessels  are 
more  sharply  bent  and  hold  the  column  of 
blood  more  rigidly;  and  also  because  the 
contents  of  the  bowel  lodge  in  the  left  low- 
er abdomen  ("Colon"  and  "Rectum")  and 
cause  more  or  less  firm  pressure  almost 
constantly. 

INJURY  is  never  a  direct  cause  of  Varicose  Veins  unless  there 
has  been  actual  damage  to  the  vein  itself  (as  by  a 
wound  penetrating  it),  or  unless  there  has  been  con- 
siderable inflammation  of  the  skin  and  deeper  tissues 
about  the  involved  vein  or  set  of  veins,  as  in  Cellulitis 
(blood-poisoning  of  the  skin  from  a  pus-containing 
wound).  This  last  cause  occasionally  results  in  Phle- 
bitis (vein-inflammation)  which  may  lead  to  vari- 
cosities. 

Tight  bandaging  or  splints,  if  over-long  continued  or 
carelessly  used,  may  by  pressure  impede  the  circulation 
and  cause  temporary  varicosity,  but  it  is  rare  for  per- 
manency to  ensue  from  such  causation. 

21 


TREATMENT:    This  is: 

i.     Palliative; 
2.     Radical. 
By  PALLIATIVE  treatment  is  meant  the  wearing 
of  an  elastic  stocking  or  bandage,  or  some  other  sup- 
port, that  will  prevent  the  further  dilating  of  the  vein9 
and  the  associated  swelling  of  the  limb. 

By  RADICAL  treatment  is  meant  the  cutting  out 
of  the  dilated  veins  by  operation.  This  is  the  safest 
and  surest  method,  and  offers  good  prospect  of  per- 
manent cure,  and  it  can  often  be  done  under  cocaine. 


22 


VII.     FRACTURES 


A  fracture  is  the  breaking  of  a  bone. 

CLASSES:    All  Fractures  are  divided  into  two  classes: 

i.     Simple   or  "Closed"   Fracture,  where    the 
bone  is  broken  without  any  external  wound  ; 
2.     Compound  or  "Open"  Fracture,  where  the 
bone  is  broken  with  an  external  wound. 
Each  of  the  above  are  further  sub-divided  into : 

A.  Comminuted  Fracture,  where  the  bone  is 
broken  into  fragments; 

B.  Green  Stick  Fracture,  where  the  bone  is 
bent  but  not  broken  completely  across. 
This  is  also  known  as  a  Partial  or  Bending 
Fracture,  and  it  commonly  occurs  in  chil- 
dren; 

C.  Multiple  Fracture,  where  the  same  bone  is 
broken  in  more  than  one  distinct  spot; 

D.  Impacted  Fracture,  where  the  broken  ends 
of  the  bone  are  jammed  together. 

FREQUENCY:  The  commonest  of  deep-seated  injuries. 
Stimson  in  his  standard  work  on  "Fractures  and  Disloca- 
tions" quotes  statistics  of  over  12,000  fractures  treated  by 
various  surgeons  at  the  Hudson  St.  Hospital  of  N.  Y.  City. 
As  to  order  of  frequency,  he  gives  the  following: 

I.     Fingers   l,737  cases 

II.  Ribs   1,396     " 

III.  Colles  (outer  forearm  bone  at  wrist)  1,007 

IV.  Ankle    907      " 

V.     Palm    873      " 

VI.     Leg  (one  or  both  bones) 764 

VII.     Skull    577     " 

VIII.     Nose   571      " 

23 


IX.     Clavicle  (Collar  Bone) 534  Cases 

X.     Femur  (Thigh)    422      " 

XI.     Lower  Jaw  415      " 

XII.     Humerus   (Arm)    325      " 

Bones  oftenest  broken   (rated  by  51,000  cases  in  the 
London  Hospitals)  : 

Forearm    18.17% 

Leg    16.02% 

Ribs    15-90% 

Clavicle    1 5.09% 

CAUSATION:     They  are  all  due  to  either  "direct,"  or  "in- 
direct violence,"  or  "muscular  action." 

DIRECT  violence  breaks  bones  at  the  point 

of  the  receipt  of  the  violence ; 
INDIRECT   violence   breaks   bones   at  a  dis- 
tance from  the  point  of  receipt  of  the  vio- 
lence;  this  is  the  common  method; 
MUSCULAR  action  breaks  bones  by  the  forced 
contraction  of  muscles ;  this  is  the  rarest 
method. 
SYMPTOMS: 

These  in  part  depend  on  the  site  of  the  frac- 
ture, but  any  broken  bone  presents  all  or 
most  of  the  following: 

1.     Abolition   of  Function,   partial   or 

complete. 
3.     Localized  pain  at  fracture  site  on 
pressure  or  motion. 

3.  Crepitation  or  Crepitus,  the  grat- 
ing feel  and  sound  produced  when 
the  broken  ends  are  rubbed  to- 
gether. 

4.  Abnormal  mobility,  so  that  the 
usual  range  of  movement  is  in- 
creased or  lessened. 

5.  Change  in  appearance,  so  that  the 

24 


part  is  swollen,  lengthened,  short- 
ened or  otherwise  deformed  or  dis- 
torted. 
A    combination    of   the   above   may 
exist  in  other  injuries  also  (as  certain 
dislocations),    but    "abnormal    mobil- 
ity" is  the  characteristic  of  a  fracture 
and  exists  in  no  other  condition. 

TREATMENT:    This  is  summed  up  in  three  parts: 
i.     Reduce  or  "set"  the  bone; 

2.  Immobilize  it  by  bandages,  plaster  of  Paris 
or  splints ; 

3.  Massage  and  gradual  motion  after  the  bone 
has  knit. 

In  Compound  Fractures,  the  accompanying 
wound  is  treated  like  any  other  wound,  but 
with  great  care  to  prevent  infection  (blood 
poisoning). 

DURATION: 

Clavicle    (collar-bone), 

Ribs, 

Forearm, 


Unite  usually  in  from 
four  to  ten  weeks. 


Unite  usually  in  from 
three  to  six  weeks. 
Fingers. 
Toes, 
Arm, 
Leg. 
Thigh. 

In  a  Compound  Fracture  the  healing  is  often  less 
rapid  than  in  a  Simple  Fracture,  owing  to  the  pres- 
ence of  the  wound ;  but  if  the  wound  be  small  and  heal 
kindly,  the  healing  process  is  little  affected. 

RESULTS:  When  the  splints  or  apparatus  are  removed,  the 
soft  parts  (muscles  and  skin)  are  more  or  less  in  a 
condition  of  ATROPHY  (wasting),  due  to  the  disuse 
of  the  muscles ;  this  occurs  even  when  an  uninjured 

25 


part  is  kept  idle,  and  hence  is  not  due  to  injury  direct. 
The  adjacent  joints  are  usually  stiff  and  more  or  less 
in  a  state  of  ANCHYLOSIS  (anchoring  or  fixation), 
due  to  inactivity;  this  may  be  either  FIBROUS 
ANCHYLOSIS,  where  the  joints  are  stiffened  by  in- 
elastic bands  of  fibre,  or  BONY  ANCHYLOSIS, 
where  the  bones  entering  into  the  formation  of  the 
joint  (usually  two)  are  involved  in  the  fracture  so  that 
union  of  their  broken  ends  is  by  firm  bony  material. 

FIBROUS  ANCHYLOSIS  can  usually  be  over- 
come by  massage,  use,  or  forcible  bending  of  the  joint 
under  the  influence  of  an  anaesthetic  or  special  ap- 
paratus; hence  no  permanency  of  great  degree  is  usual. 

BONY  ANCHYLOSIS  causes  deformity  and  dis- 
ability that  is  little,  if  any,  benefited  by  operation. 

CALLUS  is  nature's  method  of  repair  of  broken 
bone,  and  it  is  the  throwing  out  of  a  soft  cartilage- 
like material  about  the  break,  this  gluing  the  ends 
of  the  broken  bone  together  and  forming  a  sort  of 
splint,  exactly  like  the  solder  about  a  joined  lead  pipe. 
It  is  an  incident  in  the  healing  of  all  fractures,  but 
the  better  the  fracture  is  set,  the  less  will  be  the  callus ; 
it  always  persists  (it  can  be  called  a  bone  scar),  and 
by  it  a  fracture  can  be  located  for  many  years ;  it,  how- 
ever, is  gradually  converted  into  firm,  smooth  bone 
(especially  in  young  persons),  and  rarely  causes  a 
noticeable  deformity,  and  it  interferes  with  function 
only  when  it  is  near  or  within  a  joint. 

In  the  young,  it  is  frequently  so  well  absorbed  as  to 
defy  detection  even  by  means  of  X-Rays. 
DISABILITY:     This  depends  upon  the  type  of  the  fracture 
(simple  or  compound),  its  location,  method  of  treat- 
ment, and  on  the  individual. 

In  a  general  way  it  can  be  said  that  after  the  frac- 
ture of  an  extremity  (except  the  thigh)  the  individual 
can  do  some  work  in  from  five  to  eight  weeks,  and  in 

26 


twelve  weeks  the  function  is  generally  restored  enough 
to  permit  of  return  to  active  duty. 

Age  plays  some  slight  part,  as  children  usually  re- 
cover more  rapidly  than  adults. 

Stimson  says:  "Fractures  heal  as  rapidly  in  one  sex 
as  in  another,  and  in  the  old  as  rapidly  as  in  the  middle- 
aged." 

Alcoholics,  rheumatics,  syphilitics,  and  those  suffer- 
ing from  kidney  or  heart  disease,  make  poor  subjects 
(as  they  do  under  any  condition  of  illness),  and  are 
longer  in  idleness  by  one-third  to  one-half  than  the 
average. 
DEFORMITY:  If  the  fracture  be  well  set  and  of  ordinary 
type,  there  is  usually  but  slight  deformity;  but  if  it 
be  about  a  joint,  or  severe,  or  compound,  some  de- 
formity (generally  a  bowing,  swelling  or  shortening) 
always  persists. 
COMPLICATIONS:  Delirium  tremens  frequently  develops 
in  steady  drinkers. 

If  the  bone  does  not  unite  within  the  usual  time,  we 
speak  of  DELAYED  UNION ;  if  it  unites  at  an  angle 
or  with  deformity,  we  call  it  VICIOUS  or  ANGULAR 
UNION ;  if  fibre  and  not  bone  is  interposed  between 
the  broken  ends,  we  speak  of  FIBROUS  UNION,  and 
all  of  the  above  make  healing  longer  and  disability 
and  deformity  the  more  probable,  but  each  is  amenable 
to  appropriate  treatment  that  oftentimes  restores  a 
large  measure  of  function. 

Even  with  a  marked  deformity,  there  is  often  a  wide 
range  of  usefulness. 


27 


VIII.     FRACTURE    OF    THE    CLAVICLE 


This  is  a  cylindrical  bone  about  six  inches  long  that  runs 
from  the  breast  bone  (Sternum)  to  a  prominence  on  the  sum- 
mit of  the  shoulder  blade  (Acromion  Process  of  Scapula).  It 
is  bound  to  these  respective  bones  by  ligaments,  and  at  each 
articulation,  a  slight  amount  of  motion  is  possible.  (See 
Diagram.) 


Sternal  extremity. 


Shoulder  extremity. 


Left  clavicle,  upper  surface   (Gray). 


Left  clavicle,  under  surface    (Gray). 

The  word  Clavicle  means  "A  key,"  and  in  a  sense  it  is  a 
key-stone  and  is  also  somewhat  key-shaped,  although  in  out- 
line it  more  aptly  suggests  the  letter  "S." 

It  consists  of  two  extremities,  known  respectively  as  the 
INNER  and  OUTER  (or  as  Sternal  and  Acromial),  and  it  is 
arbitrarily  divided  into  an  INNER,  a  MIDDLE  and  an 
OUTER  THIRD,  each  about  two  inches  long. 
FREQUENCY:  It  is  one  of  the  most  common  fractures,  and 
various  authors  rate  it  as  third  or  fourth  in  frequency 
of  all  broken  bones. 

It  occurs  almost  exclusively  in  adults,  as  in  children 


28 


the  same  productive  violence  dislocates  the  shoulder 
oftener  than  the  adjacent  bone  is  broken. 

CAUSES:  It  is  due  to  DIRECT  VIOLENCE  (as  by  a  blow 
upon  the  bone)  occasionally,  but  usually  follows  IN- 
DIRECT VIOLENCE,  as  by  a  fall  on  the  shoulder 
(the  most  frequent  manner)  or  by  transmission  of  the 
violence  from  a  fall  upon  the  hand  or  elbow.  Another 
rare  method  of  causation  is  MUSCULAR  ACTION, 
where  a  sudden  strain  is  put  on  the  part,  as  by  heavy 
lifting  or  the  forcible  striking  of,  or  at  an  object. 

The  bone  is  oftenest  broken  at  the  outer  part  of  the 
MIDDLE  THIRD,  that  is,  about  two  inches  from  its 
junction  with  the  shoulder-blade  prominence.  Frac- 
ture of  the  INNER  THIRD  is  a  clinical  curiosity  and 
that  of  the  OUTER  THIRD  is  also  rare. 

SYMPTOMS:  A  characteristic,  almost  diagnostic  deformity 
immediately  ensues,  and  by  it  alone  the  condition  is 
usually  apparent;  viz.,  the  patient  tilts  his  head  toward 
the  affected  side,  his  shoulder  droops  downward,  for- 
ward and  inward,  and  he  supports  the  elbow  with  the 
uninjured  hand  and  is  very  guarded  in  his  movements. 
In  addition,  the  other  main  signs  of  any  fracture  are 
present,  such  as  ABNORMAL  MOBILITY  and 
CREPITUS  (i.  e.,  the  broken  ends  are  movable,  and 
they  produce  a  grating  effect  that  can  be  felt  and  often 
heard)  ;  there  is  also  LOCALIZED  PAIN  over  the 
fracture-site  and  LOSS  OF  FUNCTION— this  last 
is  shown  by  the  inability  to  place  the  affected  hand  on 
top  of  the  head,  this  being  an  almost  universal  diag- 
nostic test. 

COURSE :  Healing  is  usually  uneventful  and  union  is  gen- 
erally complete  by  the  end  of  the  fourth  week  (28  to 
30  days). 

Complications  are  exceedingly  unlikely,  and  if  they 

29 


occur  are  in  the  nature  of  "pressure  symptoms"  due 
to  involvement  of  surrounding  nerves  or  blood  vessels. 
TREATMENT:  The  aim  is,  as  in  all  fractures,  to  REDUCE 
("SET")  and  then  IMMOBILIZE  the  fragments. 

This  is  done  by  pushing  the  shoulder  up,  out  and 
back  and  holding  it  in  this  position  pending  union. 

Various  forms  of  splints  and  bandages  have  been  de- 
vised for  the  purpose,  the  most  frequently  used  of 
which  is  probably  SAYRE'S  DRESSING  (named 
after  the  late  Prof.  Sayre,  a  well-known  Surgeon)  and 
this  consists  of  two  straps  of  adhesive  plaster  (each 


Sayre's  Adhesive  Plaster  Dressing"  in  fractured  clavicle. 


about  3  inches  wide),  one  of  which  begins  at  the  centre 
of  the  breast  bone  (Sternum),  passes  under  the  sound 
arm,  across  the  back,  and  loops  around  the  damaged 
arm,  the  aim  being  to  pull  the  shoulder  back;  the  other 
strap  begins  at  the  unaffected  shoulder-blade  (Scapu- 
la), passes  over  the  summit  of  the  sound  shoulder  and 
is  looped  under  the  damaged  elbow  (it  being  next  the 
chest,  the  injured  hand  being  folded  across  the  chest 
and  resting  on  the  front  of  the  opposite  shoulder)  and 
thence  to  the  back  to  join  the  first  strap.  (See  dia- 
gram.) 

Other  forms  of  RETENTIVE  APPARATUS  are 
the  VELPEAU  BANDAGE,  the  FIGURE  OF 
EIGHT  DRESSING,  or  a  very  light  STARCH    or 


30 


PLASTER  OF  PARIS  CAST;  all  of  the  above  de- 
sign to  fold  the  damaged  arm  across  the  chest  allow- 
ing the  hand  to  rest  against  the  opposite  shoulder,  and 
thus  take  all  weight  from  the  injured  joint  and  permit 
apposition  of  the  fragments.  These  last  named  dress- 
ings are  objectionable  as  to  their  bulk,  but  mainly 
because  they  do  not  permit  ready  inspection  of  the 
part,  and  also  because  they  require  time  to  apply,  are 
insecure  and  exceedingly  uncomfortable,  being  com- 
posed of  many  turns  of  bandages  which  completely 
encircle  the  shoulder  and  arm  and  most  of  the  chest. 

Dressings  are  worn  from  20  to  30  days,  and  there- 
after a  sling  is  substituted  and  massage  and  gradual 
use  instituted. 
RESULTS:  There  is  always  more  or  less  DEFORMITY  in 
the  form  of  CALLUS  (Nature's  reparative  splint)  to 
mark  the  fracture-site ;  and  if  the  fragments  have  over- 
lapped, some  SHORTENING  will  also  persist.  De- 
spite considerable  DEFORMITY  and  SHORTEN- 
ING, function  is  speedily  and  permanently  regained, 
and  these  defects  are  hence  important  only  from  a  cos- 
metic standpoint. 

The  shoulder  (and  perhaps  the  elbow)  is  usually 
somewhat  stiff  (ANCHYLOSIS)  because  of  the  pro- 
longed disuse  and  not  from  the  injury  itself;  but  if  the 
immobilization  be  not  too  long,  and  if  massage  and 
gradual  use  are  instituted  at  the  period  named  above, 
the  stiffness  promptly  disappears  and  work  can  be  re- 
sumed in  from  6  to  8  weeks. 

Very  exceptionally  the  parts  fail  to  join  by  BONY 
UNION  and  the  fragments  coapt  by  FIBROUS 
UNION  (fibre  bridges  over  the  gap  instead  of  bone)  ; 
but  even  under  such  conditions,  function  is  practically 
perfect. 

If  re-fracture  occurs,  rarely  is  the  bone  broken  at 
the  original  site  because  the  CALLUS  there  acts  in 
the    solder-around-a-broken-pipe-manner   and    fortifies 
a  weak  place  effectually. 
31 


IX.     FRACTURE    OF    THE    HUMERUS. 
(Arm-Bone.) 

ANATOMY:  This  is  a  somewhat  cylindrical,  thick  bone,  the 
second  in  size  in  the  body,  about  10  or  12  inches  long, 
reaching  from  the  shoulder-socket  to  the  elbow ;  it 
hinges  ("Articulates")  with  the  GLENOID  CAVITY 
of  the  SCAPULA  (a  cup  shaped  depression  of  shoul- 
der-blade) and  is  bound  thereto  by  a  very  strong  band 
of  fibres  (CAPSULAR  LIGAMENT). 

It  consists  of  two  ENDS  and  a  central  portion,  the 
SHAFT.  The  upper  end  is  called  the  HEAD  and 
NECK,  the  lower  end  the  CONDYLES.  (Sec  Dia- 
gram.) 

The  HEAD  is  rounded,  very  hard  and  tough  and  is 
rarely  broken. 

The  NECK  is  that  portion  just  below  the  HEAD, 
and  because  of  the  construction,  we  speak  of  the  AN- 
ATOMICAL NECK  and  the  SURGICAL  NECK. 

THE  ANATOMICAL  NECK  is  that  part  most 
closely  joined  to  the  head,  and  because  of  its  structural 
strength,  it  is  rarely  broken. 

THE  SURGICAL  NECK  is  that  part  between  the 
anatomical  neck  and  the  shaft,  that  is,  about  3  inches 
from  the  upper  tip  of  the  bone.  It  receives  its  name 
because  it  is  the  weakest  section  of  the  bone  and  often- 
est  broken,  and  hence  requires  "Surgical"  attention 
most  frequently. 

The  SHAFT  is  that  straight  cylindrical  portion  be- 
tween the  NECK  and  the  CONDYLES.  It  is  not 
infrequently  broken,  and  if  same  occurs,  it  sometimes 
involves  a  nerve  which  runs  in  a  groove  on  the  front 
of  this  part  of  the  bone  (MUSCULO-SPIRAL  nerve), 
and  if  affected,  a  temporary  partial  paralysis  results 
so   that   a     characteristic     deformity     occurs     called 

32 


II 


ml 


ditt/wil  ti'tti- 


m  i 


>■':  , 


111 


*&> 


Left  humerus,  anterior  Left  humerus,  posterior 

view.  (Gray.)  view. 


33 


"WRIST  DROP."  in  which  the  hand  droops  and  is 
more  or  less  powerless. 

The  CONDYLES  are  the  marginal  flanges  of  the 
bone  at  the  elbow,  called  respectively  INTERNAL 
and  EXTERNAL  CONDYLE.  This  section  of  the 
bone  is  frequently  fractured,  as  is  the  ridge  leading 
from  each  CONDYLE  to  the  SHAFT;  if  this  ridge 
be  broken,  a  SUPRACONDYLOID  FRACTURE  is 
then  present. 

THE  INTERNAL  CONDYLE  is  the  more  promi- 
nent, but  the  EXTERNAL  CONDYLE  is  the  more 
often  broken. 

Because  of  its  frequency,  and  because  statements  as 
to  it  are  typical  of  the  other  types  of  fracture  in  the 
same  bone,  mention  will  be  of  fracture  of  SURGICAL 
NECK  OF  HUMERUS  only. 


34 


FRACTURED  SURGICAL  NECK  OF  HUMERUS. 


CAUSES:  Usually  follows  a  blow  or  fall  upon  the  arm  (DI- 
RECT VIOLENCE),  but  occasionally  results  from  a 
wrenching  or  straining  (MUSCULAR  VIOLENCE) 
and  from  a  fall  upon  the  elbow  or  shoulder  (INDI- 
RECT VIOLENCE). 

SYMPTOMS:  The  deformity  is  usually  typical,  inasmuch  as 
the  hand  hangs,  the  shoulder  droops  somewhat,  and 
the  elbow  is  straight  and  tilted  outward. 

In  addition,  there  are  the  usual  signs  of  all  fractures, 
such  as  ABNORMAL  MOBILITY  and  CREPITUS 
(motion  between  the  fragments  and  a  grating  sensa- 
tion that  is  often  audible)  ;  also  there  is  LOCALIZED 
PAIN  over  the  fracture-site  when  it  or  the  elbow  are 
pressed  upon. 

Accessory  signs  are  SWELLING  or  DEFORMITY 
of  the  part  and  (usually  several  hours  later)  diffused 
bluish  discoloration  from  ruptured  superficial  blood 
vessels  (ECCHYMOSIS)  ;  in  no  fracture  is  this  last 
more  marked,  and  it  may  even  extend  over  the  entire 
arm  and  sometimes  reaches  the  chest  also. 

An  individual  with  such  an  injury  is  in  great  pain 
and  the  arm  is  useless  and  requires  immediate  atten- 
tion. 

TREATMENT:  The  aim  is  (as  in  all  fractures)  to  RE- 
DUCE ("SET")  the  broken  fragment  and  then  IM- 
MOBILIZE them  in  some  form  of  splint  or  apparatus. 
Because  the  side  of  the  chest  forms  a  natural  and 
practically  immovable  splint,  it  is  taken  advantage  of 
and  the  arm  is  bound  thereto  (with  cotton  or  a  "Pad" 
under  the  armpit)  by  bandages  or  Plaster  of  Paris,  a 
helmet  or  cap  being  placed  over  the  shoulder  summit 
(made  of  Plaster,  Metal  or  Felt),  the  elbow  being  at 
right  angles  and  supported  in  a  sling. 

35 


In  certain  instances,  more  complicated  and  uncom- 
fortable apparatus  is  required,  but  the  above  fits  the 
average  case. 

Union  of  the  bone  is  prompt  and  is  generally  com- 
plete in  from  30  to  40  days  (4-6  weeks),  but  prior  to 
this  time  (usually  at  the  end  of  the  third  week)  the 
apparatus  is  removed  daily  so  that  massage  can  be 
given  to  prevent  stiffness  (ANCHYLOSIS)  of  the 
shoulder  and  elbow  and  wasting  (ATROPHY)  of  the 
muscles  from  disuse. 

The  more  modern  Surgery  advises  that  all  fractures 
(especially  if  near  a  joint)  receive  massage  as  early  as 
the  third  week,  and  that  in  the  fourth  week,  some  mo- 
tion of  the  involved  joints  be  made;  by  this  method, 
repair  is  hastened  and  the  disability  period  is  shortened 
from  one  to  three  weeks. 

SEQUELS:  A  certain  amount  of  stiffness  (ANCHYLOSIS) 
of  the  shoulder  and  elbow,  with  wasting  of  the  muscles 
(ATROPHY)  is  to  be  expected  from  the  long  disuse, 
but  if  massage  be  given  early,  and  if  the  parts  be  kept 
actively  moved,  disappearance  of  the  above  promptly 
occurs,  and  within  seven  or  eight  weeks,  function 
should  be  restored. 

CALLUS  (Nature's  reparative  splint)  is  generally 
inexcessive,  but  in  an  adult,  enough  of  it  persists  to 
mark  the  fracture-site  through  life. 

SHORTENING  of  the  arm  occasionally  occurs  as 
does  DEFORMITY,  but  neither  is  usually  great 
enough  to  produce  DISABILITY. 


36 


X.     COLLES'  FRACTURE. 


This  receives  its  name  because  best  described  Tin 
1814)  by  an  Irish  Surgeon  called  COLLES. 

It  is  a  fracture  of  the  lower  end  of  the  Radius  (outer 
forearm  bone,  thumb  side)  about  1/3-inch  to  3/4- 
inch  above  the  wrist-joint. 

ANATOMY:  The  RADIUS  (which  means  "A  rod")  is  a 
thin  bone  about  8  to  9  inches  long  reaching  from  the 
wrist  to  about  1  inch  below  the  elbow.  It  consists  of 
two  ENDS  and  a  central  portion,  the  SHAFT.  The 
upper  end  is  rounded  and  is  called  the  HEAD  and 
does  not  come  into  contact  with  the  elbow  joint  unless 
the  latter  is  flexed  (bent)  ;  the  diameter  of  the  bone 
here  is  about  3/4-inch,  and  because  it  is  well  protected 
and  strong,  it  is  rarely  fractured,  but  not  infrequently 
dislocated.  The  lower  end  of  the  bone  is  thinner  than 
the  upper,  and  at  its  outer  part  there  is  a  projecting 
prominence  known  as  the  STYLOID  PROCESS; 
this  can  be  felt  by  grasping  the  lateral  margins  of  the 
joint.  It  is  just  above  the  STYLOID  PROCESS  that 
the  above  fracture  occurs,  hence  it  is  sometimes  re- 
ferred to  as  "FRACTURE  OF  THE  BASE  OF  THE 
STYLOID  PROCESS."     {See  Diagrams.) 

FREQUENCY:  Next  to  the  ribs,  COLLES'  FRACTURE 
is  probably  the  most  frequent  broken  bone;  fractures 
of  the  upper  extremity  constitute  47.89%  of  all  frac- 
tures. It  is  more  frequent  in  the  aged  than  in  youth, 
as  in  the  latter,  dislocations  and  soft  part  injuries  oc- 
cur under  the  same  sort  of  violence. 

CAUSES:  Falls  on  the  outstretched  hand,  resulting  in  trans- 
mitted violence  to  the  wrist  causes  practically  ALL 
such  breaks;  this  is  what  is  known  as  INDIRECT  VI- 
OLENCE.    Rarely,  DIRECT  VIOLENCE  produces 

37 


fl'MIt    DICITOKVM 


|frL-.    «    iftMH  fotuei* 


Bones  of  the  left  forearm,  anterior  surface   (Gray). 


38 


the  injury,  as  for  example  a  blow  directly  over  the 
wrist. 

In  this  connection  it  may  be  stated  that  the  other 
bone  of  the  forearm  (ULNA)  paralleling  the  RADIUS 
does  not  join  the  wrist-joint,  but  it  does  join  (or  "Arti- 
culate") with  the  elbow;  hence  it  is  that  wrist-violence 
breaks  the  RADIUS,  and  elbow-violence  breaks  the 
ULNA. 

SYMPTOMS:  The  resulting  deformity  is  characteristic  and 
by  it  alone  a  diagnosis  can  be  made  on  inspection ;  this 
deformity  is  known  as  the  "SILVER  FORK  DE- 
FORMITY" because  the  back  of  the  wrist  is  raised  at 
the  fracture-site,  and  the  hand  and  fingers  tilt  down- 
ward, and  the  forearm  is  straight ;  hence  the  forearm 
represents  the  handle  of  the  fork,  the  raised  wrist  cor- 
responds to  the  central  part  of  the  fork,  and  the  fingers 
are  the  tines. 

Swelling  of  the  entire  wrist,  a  pushing  up  of  the 
STYLOID  PROCESS,  deepening  of  the  wrinkles  at 
the  back  of  the  wrist,  pain  and  abolition  of  function 
are  other  signs ;  occasionally,  Crepitation  (grating  of 
the  broken  ends)  and  False  Motion  (fragments  moving 
wjjen  manipulated  side-wise)  are  also  obtainable. 

It  is  possible,  but  very  improbable  that  a  person  with 
such  a  fracture  would  continue  long  without  knowl- 
edge that  a  serious  injury  had  occured  because  the  pain 
and  swelling  are  usually  great  enough  to  demand  im- 
mediate attention. 

TREATMENT:  The  two  essentials,  as  in  all  fractures,  are 
REDUCE  ("SET")  and  IMMOBILIZE. 

In  no  fracture  is  Reduction  ("Setting")  more  import- 
ant, and  if  this  be  properly  performed,  little  deformity 
and  practically  no  disability  ensues ;  it  is  accomplished 
by  pulling  on  the  hand  and  pushing  on  the  back  of  the 
wrist  so  as  to  bring  the  broken  ends  into  apposition. 

39 


Ulna 


TlacliuS 


r.5l  M 


* 


Ak 


i% 


m 


%$$\ 


\i 


R 


Bones  of  the  left  forearm,  posterior  surface. 


40 


This  is  not  always  easy  and  frequently  the  fragments 
are  IMPACTED  (jammed  together)  and  an  anaesthe- 
tic is  needed. 

After  Reduction,  some  form  of  wooden  or  Plaster  of 


f?<vr/irts 

tl.M0H.OMWI    ULtl* 


3.OIT00"" 

fl>oruNOU» 


Bones  of  the  left  hand  and  wrist,  front  surface  (Gray). 

Paris  splint  is  applied  to  the  front  and  back  of  the 
forearm,  reaching  from  the  palm  to  just  below  the 


41 


bent  elbow;  a  main  feature  is  to  permit  the  FINGERS 
TO  BE  FREELY  MOVED  as  otherwise  they  will 
stiffen  from  disuse  and  add  greatly  to  the  disability 
period  because  the  tendon-sheaths  become  inflamed 
resulting  in  what  is  called  "Teno-Synovitis." 


rjpu* 


taea 


"*»•«* 


rpa* 


PhaU 


"f*i 


StlJbu, 


itf/tew. 


t/lfir 


Bones  of  the  left  hand  and  wrist,  back  surface  (Gray). 

Union  of  the  bone  is  usually  complete  in  a  month, 
and  thereafter  a  less  bulky  dressing  is  applied,  massage 
is  given,  the  wrist  moved,  and  in  from  6  to  8  weeks, 


42 


work  can  be  done;  many  of  the  better  Surgeons  coun- 
sel removal  of  the  splint  in  three  weeks,  daily  massage 
twice  a  day  with  replacement  of  the  splint,  and  the 
abolition  altogether  of  the  latter  in  four  weeks.  The 
usual  Dispensary  practice,  however,  is  splintage  for 
five  or  six  weeks. 

RESULTS:  The  wrist  is  always  more  or  less  stiff  (ANCHY- 
LOSIS) and  the  adjacent  parts  wasted  (ATRO- 
PHIED), these  depending  in  part  on  the  severity  of  the 
injury,  but  mainly  on  the  duration  of  splintage  and 
the  early  use  of  massage.  If  the  Splints  are  removed 
promptly,  and  if  the  parts  be  exercised,  this  wasting 
and  stiffness  soon  disappears;  but  in  the  aged,  and  in 
rheumatics,  it  may  persist  for  many  months,  and  oc- 
casionally permanently. 

Some  DEFORMITY  over  the  fracture-site,  in  the 
form  of  more  or  less  swelling  is  not  infrequent,  but 
this  can  be  great  in  amount  without  disabling  the 
joint. 

If  re-fracture  occurs,  after  a  lapse  of  some  months, 
the  original  site  is  rarely  involved  because  the  CAL- 
LUS (Nature's  reparative  splint)  makes  that  section 
of  the  bone  stronger  than  before.  Once  this  injury 
has  occurred,  Callus  can  be  detected  for  many  years; 
in  adults  over  40  it  practically  never  disappears. 


43 


XI.     FRACTURE     OF     THE     RIBS. 


ANATOMY:  There  are  twelve  ribs  on  each  side,  the  seven 
upper  being  called  TRUE  RIBS  because  they  are  bony 
and  firmly  attached  to  the  STERNUM  (breast  bone), 
and  the  lower  five  are  known  as  FALSE  RIBS    be- 


Relations  of  the  lungs  to  the  anterior  chest-wall   (after  Joessel). 

cause  they  are  somewhat  cartilaginous  and  unattached 
to  any  bone  in  front;  of  these  five,  THREE  are  joined 
to  the  ribs  above  by  cartilage,  but  TWO  are  unat- 
tached or  free,  and  are  called  FLOATING  RIBS.  (See 
Diagram.) 

The  ribs  form  a  bony  cage  or  lattice  work,  and  with 


44 


the  STERNUM  (breast  bone)  in  front  and  the 
VERTEBRAL  COLUMN  (spine)  in  back,  go  to  make 
up  the  thorax  (chest)  or  THORACIC  CAVITY,  con- 
taining the  HEART  and  LUNGS,  the  latter  being  cov- 
ered by  a  double  layer  of  fibre  called  the  PLEURA 
which  also  acts  as  a  lining  for  the  inner  side  of  the 
ribs. 

Between  each  rib  is  a  space — INTERCOSTAL 
SPACE — filled  in  by  muscle,  and  over  each  rib  are 
many  layers  of  muscle,  and  the  bony  part  of  each  rib 
is  further  protected  by  a  fibrous  covering  such  as  exists 
on  every  bone,  PERIOSTEUM.  All  this,  together 
with  considerable  motility  and  elasticity,  acts  as  a 
protective,  so  that  when  a  rib  is  broken,  separation  of 
the  broken  ends  is  usually  slight,  and  the  fracture  is 
generally  more  of  a  slit  or  crack  or  fissure  than  an 
actual  overlapping  separation  such  as  occurs  in  other 
bones. 

The  LUNGS  are  separated  from  the  inner  side  of 
the  ribs  by  the  PERIOSTEUM  (fibrous  bony  cover- 
ing) and  by  the  PLEURA  (fibrous  sac  lining  the  chest 
cavity)  and  they  do  not  come  into  contact  with  the 
latter  except  during  very  full  inspiration ;  hence 
it  is  that  a  broken  rib  (unless  much  displacement  of 
the  broken  ends  occur)  rarely  penetrates  or  damages 
the  lung. 

The  HEART  is  overlapped  to  a  very  great  extent 
by  the  lung,  and  hence  fractures  of  the  ribs  almost 
never  involve  it. 
FREQUENCY:  A  very  common  injury,  and  of  all  fractures, 
various  authors  rate  them  as  second,  third  or  fourth 
in  frequency;  Stimsoivs  work  on  "Fractures  and  Dis- 
locations" (perhaps  the  best  known  authority)  rates 
the  fracture  as  the  second  in  order  of  occurrence.  Von 
Bergman's  Surgery  is  one  of  the  latest  general  text- 
books and  it  states  that  the  injury  is  the  second  most 

45 


frequent  as  to  fractures,  constituting  from  15.9  to  16.07 
per  cent,  of  all  fractures. 

LOCATION:  Ribs  are  broken  at  the  most  exposed  portion 
of  the  chest,  where  they  are  longest  and  most  bulg- 
ing; hence  the  5th,  6th  and  7th  ribs  are  the  most  often 
involved,  the  fracture  site  being  generally  in  the  line 
of  the  armpit  ("Axillary  Line").  The  location  can 
be  fixed  when  it  is  known  that  the  nipple  is  close  to 
the  fifth  rib. 

Fracture  of  the  first  rib  is  a  museum  curiosity. 
The  last  two  ribs,  the  nth  and  12th— the  "FLOAT- 
ERS"— are   also   rarely   broken,   because   they   extend 
only  half  way  round  the  body,  and  their  forward  end 


A  and  B,  typical  ribs;  C,  first  rib;  D,  twelfth  rib.  A:  1,  place  of  attach- 
ment to  vertebral  column  (spine) ;  6,  attachment  to  cartilage  which 
joins  it  to  the  sternum  (breast  bone). 

is  unattached,  permitting  wide  range  of  motion  if  vio- 
lence is  applied  over  them ;  Stimson  says  that  he  has 
only  seen  two  cases  of  fractured  twelfth  rib,  and 
quotes  another  authority  who  states  that  there  are 
only  two  others  in  all  literature. 

The  strongest  portion  of  the  rib  is  at  its  attached 
portions,  that  is,  where  it  fits  into  the  Spine  and 
STERNUM  (breast  bone),  the  former  being  the 
stronger.     (See  Diagram.) 


46 


CAUSATION:  Occasionally  fracture  occurs  by  MUSCULAR 
ACTION,  as  by  lifting,  or  coughing,  or  sneezing. 

Usually  DIRECT  VIOLENCE  is  responsible,  as  by 
a  blow  over  the  front  or  side  of  the  chest,  the  break 
occurring  at  the  place  of  impact  or  being  transmitted. 
The  mechanism  of  the  breakage  of  ribs  has  often 
been  compared  to  a  hickory  barrel  hoop  attached  at 
both  ends;  depending  on  where  it  is  struck,  the  frac- 
ture occurs,  but  generally  the  widest  part  of  the  hoop 
is  less  resistant — this  corresponds  to  the  middle  of  a 
rib  which  is  in  the  armpit  line,  as  above  stated. 

TYPES:  "Partial"  or  "Incomplete"  fractures  are  rare  and 
hard  to  diagnose  with  certainty  because  their  symp- 
toms almost  equally  well  fit  a  Contusion  or  Sprain  of 
a  chest  muscle. 

"Compound"  fractures  (where  the  bone  pierces  the 
skin)  are  also  rare. 

"Complete"  fractures  are  the  most  usual,  and  they 
generally  cause  a  more  or  less  vertical  crack  or  split  of 
the  bone. 

SYMPTOMS:    There  are  three  diagnostic  signs: 

i.  Localized  tenderness  over  the  broken  site 
on  breathing  and  pressure  and  exertion ; 

2.  Embarassed  breathing;  generally  a  short- 
ness of  breath,  with  a  catch  in  the  speech 
and  disinclination  to  talk; 

3.  Crepitus  (clicking)  on  rubbing  the  broken 
ends  or  on  listening;  or  abnormal  motion 
between  the  fragments. 

Coupled  with  the  above,  is  frequently  a  character- 
istic anxious  look;  a  favoring  of  the  injured  side  in 
walking  or  moving;  perhaps  some  duskiness  of  the 
lips;  occasionally  a  short  cough;  and  if  the  lung  has 
been  punctured  (sometimes  even  without  puncture) 
blood  is  expectorated  in  variable  quantities. 
TREATMENT:     The  one  indication  is  to  limit  the  normal 

47 


up  and  down  motion  of  the  rib,  and  this  is  done  by 
placing  a  strap  of  ADHESIVE  PLASTER  (about 
3  inches  wide)  three-fourths  around  the  chest,  making 
the  fixed  ends  at  the  spine  and  sternum  (breast 
bone)  ;  this  adheres  firmly  and  is  applied  while  the 
patient  has  deeply  exhaled  so  that  in  ordinary  respira- 
tion it  will  force  him  to  take  shallow  breaths  and  act 
as  a  splint. 

Some  of  the  older  Surgeons  advise  plaster  of  Paris 
encircling  the  chest;  this  is  obsolete  now  because  it 
cannot  be  applied  tightly  enough  to  act  as  a  splint. 

COURSE:  Knitting  is  very  rapid,  and  to  quote  Stimson: 
".  .  .  .  the  course  of  an  uncomplicated  fracture  is 
usually  quite  uneventful ;  the  patient  remains  quiet, 
sometimes  keeping  his  bed,  and  breathes  carefully  and 
superficially  to  avoid  pain ;  after  two  or  three  weeks 
he  finds  these  precautions  unnecessary,  and  the  sur- 
geon on  examination  finds  that  local  tenderness  has 
disappeared  and  that  crepitus  can  no  longer  be  ob- 
tained.   ..." 

Healing  is  generally  complete  in  from  three  to  four 
weeks,  and  after  this  period  light  work  can  be  resumed ; 
for  some  weeks  thereafter  it  is  not  uncommon  for 
justifiable  claim  to  be  made  of  localized  pain  on  deep 
breathing  or  exertion,  but  the  vast  majority  of  patients 
cease  to  even  comment  after  three  months. 

There  are  many  cases  in  which  the  individual  has 
kept  on  working  with  a  broken  rib,  and  football  play- 
ers and  boxers  have  many  times  sustained  such  an 
injury  and  continued  physical  exertion. 

It  is  a  very  common  Hospital  and  Dispensary  expe- 
rience to  have  laborers  return  to  work  after  having  a 
broken  rib  bound  up  with  a  "Strap  of  Adhesive 
Plaster." 

An  uncomplicated  broken  rib  presents  no  difficulties, 
and  of  all  fractures  there  is  none  that  Nature  has  en- 

48 


dowed  with  more  perfect  natural  splints  (the  muscles) 
and  none  in  which  healing  is  more  rapid  and  uniform. 
COMPLICATIONS:  Because  of  the  proximity  of  the  Pleura 
(fibrous  lining  of  the  chest),  in  some  fractured  ribs 
there  is  an  inflammation  of  this  tissue — hence  we  have 
TRAUMATIC  PLEURISY.  This  is  usually  localized 
to  the  vicinity  of  the  fracture  and  subsides  before 
healing  is  complete,  and  rarely  causes  serious  delay 
in  convalescence.  If  it  is  due  to  the  injury,  it  develops 
within  a  day  or  two  thereafter,  and  its  treatment  (like 
that  of  Pleurisy  of  other  origin)  is  that  of  the  broken 
rib,  plus  remedies  to  allay  the  accompanying  cough. 

The  above  Pleurisy  is  called  a  "Dry"  Pleurisy  to 
distinguish  it  from  a  "Wet"  Pleurisy  which  occasion- 
ally follows  it;  this  means  that  the  normal  fluid  be- 
tween the  two  layers  of  the  pleura  (the  latter  tissue 
acting  as  a  protective  and  also  as  a  lubricant  for  the 
motion  of  the  lung)  has  increased  in  amount,  result- 
in  PLEURISY  WITH  EFFUSION  ("water  on  the 
lungs"). 

Still  more  rarely,  this  serum-like  fluid  turns  into 
pus  and  we  then  have  PURULENT  PLEURISY,  also 
called  EMPYEMA. 

If  the  lung  has  been  ripped  by  the  broken  end  of  a 
rib  penetrating  it  (which  is  very  rare  except  in  severe 
crushing  injuries),  there  may  be  extensive  bleeding 
from  the  torn  blood  vessels  and  we  have  HAEMORR- 
HAGIC  PLEURISY. 

The  above  varieties  of  "WTet"  pleurisy  are  unusual 
complications  and  commonly  are  the  associates  of 
severe  injuries  only,  in  which  Compound  (break  pene- 
trating the  skin)  Fracture  has  occurred,  usually  of 
many  ribs. 

The  "wet"  products  are  removed  by  inserting  a 
needle,  or  in  some  instances,  by  cutting  out  a  portion 
of  a  rib  and  inserting  a  tube  to  drain  away  the  ef~ 
fusion. 

49 


l'XEUMOXIA  is  also  an  occasional  complicating 
development  and  is  then  called  TRAUMATIC  PNEU- 
MONIA, and  it  occurs  from  direct  injury  to  the  lung 
by  a  broken  fragment  of  the  rib,  or  less  often,  by  ex- 
tension of  a  Pleurisy. 

Its  course  and  treatment  follows  that  of  Pneumonia 
from  the  usual  origin. 

Occasionally  the  end  of  a  rib  may  penetrate  the 
Pleura  or  the  Lung  and  allow  some  air  from  the  air- 
tight Thorax  (chest)  to  escape  under  the  skin,  giving 
rise  to  another  complication  called  SKIN  EM- 
PHYSEMA ;  this  shows  itself  in  a  bloated  appearance 
about  the  fracture  site,  and  the  air  bubbles  may  dis- 
sect the  skin  over  the  entire  chest  and  even  go  as  high 
as  the  face  and  swell  it  enough  to  close  the  eyes,  but 
it  almost  always  subsides  in  a  short  time,  either  spon- 
taneously or  through  openings  made  purposely  to  per- 
mit its  escape. 

NEURALGIA  of  one  of  the  nerves  lying  on  the 
margin  of  the  broken  rib  (Intercostal  Nerve)  may 
ensue,  giving  rise  to  INTERCOSTAL  NEURALGIA, 
but  this  is  very  uncommon  and  usually  indicates  a 
rheumatic  or  neurotic  individual. 

SEQUELS:  CALLUS  (Nature's  reparative  solder)  almost 
always  persists  in  sufficient  amount  to  be  felt  and  often 
seen ;  but  if  the  displacement  between  the  bones  has 
been  slight,  and  if  the  union  has  been  firm  and  true, 
the  CALLUS  will  be  less  prominent.  In  a  general 
way,  persisting  CALLUS  follows  broken  ribs  in  an 
adult  in  amount  sufficient  to  diagnose  the  injury  by  it 
alone  within  a  period  of  five  years ;  absorption  of  it  is 
more  rapid  in  some  than  in  others,  but  the  above  state- 
ment is  conservative. 

Very  rarely  the  Callus  is  stated  to  be  more  promi- 
nent on  the  inner  than  the  outer  surface  of  the  rib, 
and   in   such    instances   an    X-ray   examination   alone 

50 


(after  a  lapse  of  some  years)  would  be  determinative; 
but  generally  the  Callus  is  uniformly  distributed  in  the 
solder-around-the-broken-pipe-manner. 

Even  though  the  Callus  be  large  in  amount  it  causes 
no  difficulty  as  a  rule. 

PARALLEL  CONDITIONS:  Pleurisy  from  other  causes, 
even  if  extensive  (and  under  such  circumstances  it 
usually  is)  once  recovered  from  does  not  rob  the  pa- 
tient of  any  of  his  chances  and  does  not  disable. 

In  practically  all  cases  of  Pneumonia  there  is  more 
or  less  Pleurisy,  but  even  with  great  involvement  of 
the  Pleura  and  the  Lung,  once  recovered  from,  there 
are  in  the  vast  majority  of  cases  no  after  effects. 

The  same  is  true  of  collections  of  fluid  in  the  chest 
from  causes  other  than  injury;  the  pleura  then  usually 
remains  somewhat  thickened,  but  this  constitutes  more 
of  a  clinicial  than  a  disabling  feature,  and  Life  In- 
surance and  Civil  Service  examinations  can  be  passed 
with  such  manifestations  persisting. 

Even  where  a  Pleurisy  has  turned  into  pus  (Em- 
pyema) and  where  a  piece  of  one  or  more  ribs  has  been 
cut  away  to  drain  same  (it  is  not  uncommon  to  re- 
move an  inch  or  more  of  several  ribs),  the  patient  often 
recovers  full  strength,  even  though  very  much  weak- 
ened by  an  associated  attack  of  Pleuro-Pneumonia  of 
which  the  Empyema  is  a  sequel.  In  the  event  of 
such  an  operation,  the  patient  may  have  a  rubber 
tube  stuck  into  the  chest  cavity  (through  a  hole  made 
by  cutting  out  a  piece  of  one  or  more  ribs)  and  pus  may 
drain  for  months,  the  chest  "cave  in,"  and  yet  re- 
covery is  very  often  complete. 

The  pleura  is  punctured  by  a  needle  with  impunity 
in  suspected  cases  of  fluid  within  the  chest  cavity,  and 
it  readily  resumes  its  function ;  hence  it  can  stand 
considerable  insult  from  injury  and  disease  without 
resultant  permanent  weakness  to  the  individual. 

51 


XII.     FRACTURE    OF    NECK    OF    FEMUR. 


By  this  is  meant  a  fracture  at  the  bent  portion  of  the 
thigh  bone,  where  it  joins  the  hip-socket. 

ANATOMY :  THE  FEMUR  or  thigh  bone  is  the  longest  and 
strongest  bone  of  the  body,  and  it  is  divided  into  three 
sections.     (See  Diagram.) 

The  upper  portion,  which  fits  into  the  socket  of  the 
hip  joint  (technically  known  as  the  Acetabulum),  is 
called  the  Head  and  Neck. 

The  long  straight  portion  below  these  is  known  as 
the  Shaft. 

And  the  expanded  part  below  this  is  technically 
known  as  the  Condyles;  that  is,  the  flanges  at  the  end 
of  the  bone. 

FRACTURE  MAY  OCCUR  at  any  portion  of  the 
entire  bone,  but  very  commonly  occurs  at  the  upper 
portion ;  that  is,  the  neck  of  the  femur.  This  is  known 
as  the  fracture  of  the  aged,  and  in  any  injury  to  the 
hip  joint  in  a  person  over  45  years  of  age,  it  is  a  good 
rule  to  suspect  this  fracture  until  it  can  be  excluded 
with  absolute  safety. 
FREQUENCY:  It  is  very  common,  and  is  liable  to  occur 
in  those  predisposed  under  conditions  of  slight  vio- 
lence, as  by  a  trip,  or  an  effort  to  regain  one's  balance; 
and,  in  certain  old  people  (because  of  the  fragility  of 
the  bone  and  the  lack  of  bony  and  the  preponderance 
of  cartilaginous  tissue),  it  not  infrequently  happens 
even  from  such  slight  exertion  as  the  attempt  to  get 
out  of  bed  hurriedly. 

It  may  occur  as  a  result  of  Direct  Violence,  that  is, 
by  a  fall  immediately  over  the  hip  joint;  or  by  Indi- 
rect Violence,  as  by  a  fall  on  the  feet,  or  a  wrench  of 
the  joint. 
VARIETIES :     Fracture  of  the  neck  of  the  thigh-bone  is  di- 

52 


Jrrin^^m 


'"Wy, 


Right  femur,  anterior  surface.  Right  femur,  posterior  surface. 


53 


vided  according  to  its  relation  to  the  Capsule  of  the 
bone,  this  being  the  strong  band  of  fibre  which  en- 
circles the  head  and  the  neck  of  the  bone  and  binds  it 
by  atmospheric  pressure  into  the  hip  joint  socket;  this 
pressure  is  so  great  that  when  this  capsular  band  of 
fibres  is  torn,  an  exploding  sound  occurs. 

If  the  fracture  occurs  within  the  attachment  of  this 
band  of  fibres,  it  is  known  as  an  INTER — (or  Intra)  — 
CAPSULAR  fracture  of  the  neck  of  the  femur.  (See 
Diagram.) 


Lines  of  Fracture  of  Upper  Extremity  of  Femur. 

If  it  occurs  outside  of  this  band  of  fibres,  it  is  known 
as  an  EXTRA-CAPSULAR  fracture  of  the  neck  of 
the  femur. 

This  nomenclature,  however,  is  somewhat  obsolete, 
and  has  been  replaced  by  a  classification  of: 

i.  Fracture  through  the  neck  of  the  femur, 
which  corresponds  to  the  intra-capsular 
variety; 
2.  And  Fracture  at  the  base  of  the  neck  of 
the  femur,  which  corresponds  to  the  extra- 
capsular variety. 

54 


In  former  times,  attempts  were  made  to  differenti- 
ate between  these  two  types  of  fracture  by  the  symp- 
toms, but  this  is  not  now  regarded  as  good  surgery, 
nor  is  it  possible  except  by  X-ray  examination,  and  for 
all  practical  purposes  no  attempt  is  made  to  needlessly 
separate  a  break  in  this  location. 

SYMPTOMS:     There  arc  certain  cardinal  symptoms  of  this 
fracture,  and  they  can  be  stated  to  be: 

i.  Disturbance  of  function,  so  that  the  indi- 
vidual is  unable  to  raise  the  foot  from  the 
bed,  or  rotate  it  in  its  socket,  although 
walking  is  occasionally  possible  by  great 
effort. 

2.  Pain  on  motion  of  the  part,  whether  move- 
ment be  voluntary  or  made  by  the  exam- 
iner. 

3.  Deformity  of  the  extremity,  so  that  the  foot 
is  turned  upward,  tilted  outward  (techni- 
cally known  as  eversion),  or  tilted  inward 
(technically  known  as  inversion).  With 
this  is  associated  more  or  less  shortening. 

4.  Other  associated  symptoms,  not  always 
present,  are  discoloration  about  the  hip 
joint ;  occasionally  crepitus  (a  grating 
sound  made  by  the  rubbing  of  the  broken 
bony  ends)  ;  and  sometimes  abnormal  full- 
ness in  the  groin  or  in  the  region  of  the 
buttocks. 

Many  persons  are  able  to  walk  with  effort  immedi- 
ately receiving  this  fracture,  but  after  a  short  inter- 
val, function  is  lost. 

TREATMENT:  This  can  be  summed  up  under  two  head- 
ings: 

1.  Reduction  or  setting  of  the  fracture. 

2.  Immobilization  of  the  part. 

55 


Setting  is  very  readily  accomplished  by  traction  on 
the  foot  which  aims  to  place  the  extremity  in  the  same 
straight  line  as  the  long  axis  of  the  thigh. 

Immobilization  takes  the  form  of  splintage  by  var- 
ious forms  of  apparatus. 

The  commonest  of  these  may  be  said  to  be  what  is 
technically  known  as  the  LONG  SIDE-SPLINT;  that 
is,  a  thin  piece  of  basswood  about  5  inches  wide  and 
about  1/2-inch  thick,  which  is  padded  by  cotton  and 
bandages,  and  which  reaches  from  the  arm-pit  to  be- 
low the  foot,  and  the  thigh  and  leg  and  foot  are  bound 
to  this  by  turns  of  bandages,  sand-bags  being  placed 
on  the  inner  side  of  the  injured  member  to  prevent  any 
movement  of  the  limb. 

A  PLASTER  OF  PARIS  CAST  is  frequently  used, 
and  this  begins  at  the  toes  and  runs  up  the  leg,  and 
thigh,  and  across  the  abdomen,  and  it  is  technically 
known  as  a  PLASTER  OF  PARIS  SPICA  BAND- 
AGE. 

Both  of  these  are  occasionally  reinforced  by  a  pul- 
ley attachment  fastened  to  the  leg,  with  a  weight 
dangling  from  the  foot,  so  as  to  overcome  the  tendency 
to  shorten — this  weight  varying  from  4  lbs.  to  15  lbs. 
— and  it  is  suspended  over  the  foot  of  the  bed,  and 
changed  from  time  to  time,  and  usually  can  be  dis- 
pensed with  after  the  second  week,  if  not  before. 

A  third  form  of  treatment  is  that  known  as  the 
BUCK'S  EXTENSION  APPARATUS;  and  by  this 
is  meant  a  special  form  of  splint  which  is  bound  to  the 
under  surface  of  the  injured  leg,  this  being  grooved  so 
as  to  rest  in  tracks  on  another  piece  of  apparatus 
which  rests  on  the  bed,  and  from  the  patient's  foot  a 
pulley  arrangement  is  attached  with  a  weight,  so  that 
the  grooved  portion  of  the  apparatus  runs  on  the  track, 
and  allows  considerable  up  and  down  movement  of  the 
individual,  but  in  such  a  manner  that  the  fragments 


56 


are  not  displaced.  This  type  of  apparatus,  however, 
finds  its  chief  use  in  fractures  of  the  shaft  or  middle  of 
the  hone,  where  there  is  greater  tendency  for  over- 
riding- and  displacement  of  the  broken  fragments. 

After  all  the  apparatus  is  removed,  the  parts  are 
gently,  then  forcibly  moved,  and  later  on  massage  is 
resorted  to  so  as  to  prevent  stiffness  and  wasting  of 
the  part. 

DURATION:  Depending  upon  the  type  of  the  fracture,  but 
more  especially  on  the  individual's  general  condition, 
immobilization  or  splinting  is  determined. 

If  the  individual  be  in  good  general  condition,  he 
is  kept  in  bed  from  three  to  six  weeks ;  but  if  this  is 
bad,  he  is  taken  out  of  bed  almost  immediately,  and 
the  general  health,  rather  more  than  the  local  fracture, 
is  the  object  of  treatment. 

This  fracture,  above  and  beyond  all  others,  is  asso- 
ciated with  a  stagnation  of  the  circulation  through  the 
kidneys  and  the  lungs,  producing  in  the  first  named 
what  corresponds  to  a  congestion  of  the  kidneys,  often 
developing  into  URAEMIA;  and  in  the  latter  to  a  low 
grade  of  pneumonia  (HYPOSTATIC  PNEU- 
MONIA) or  OEDEMA  of  the  lungs. 

Both  of  these  conditions  are  dependent  on  the  lack 
of  heart-pumping  power  to  propel  the  blood  through 
the  kidneys  and  the  lungs,  and  the  watery  part  of  the 
blood  (because  of  the  patient's  lying  so  long  on  his 
back)  oozes  out  and  the  parts  become  literally  water- 
logged and  drown  in  their  own  secretions. 

It  is  rare  in  the  aged  for  a  fracture  of  the  neck  of  the 
femur  to  unite  by  what  is  known  as  BONY-UNION; 
and  the  best  that  can  be  hoped  for  is  that  the  fragments 
may  co-apt  by  bands  of  fibre  joining  them,  and  to  this 
the  name  of  FIBROUS-UNION  is  given. 

57 


For  all  practical  purposes  the  latter  acts  as  well  as 
the  former,  and  is  what  is  aimed  at  in  the  treatment. 

DISABILITY  is  generally  absolute  for  six  to  ten  weeks,  at 
least,  and  thereafter  the  individual  is  able  to  get 
around  with  crutches ;  at  the  end  of  ten  to  twelve  weeks 
he  is  usually  able  to  get  about  with  a  cane  or  crutch, 
and  at  the  end  of  the  third  month  can  usually  get 
about  with  little  or  no  support. 

RESULTS :     There  are  certain  almost  invariable  sequelae  of 
this  condition,  and  they  may  be  said  to  be: 
i.     Limp  more  or  less  pronounced; 

2.  Eversion  (turning  out),  or  Inversion  (turn- 

ing in)  of  the  foot ; 

3.  Shortening,  with  more  or  less  stiffness  of 

the   hip   joint,   and   occasionally   also   of 
the  knee  and  ankle  joint; 

4.  Lesser  accompaniments     are     occasionally 

•^Excessive    Callus    (Nature's    reparative 
tissue  about  the  fractured  site)  ; 

5.  Fullness  in  the  groin; 

6.  Shrinkage  or  "ATROPHY"  of  the  muscles 

from  disuse,  thus  obliterating  the  "glu- 
teal fold;"  that  is,  the  crease  at  the  junc- 
tion of  the  buttocks  and  the  thigh. 

The  Limp  is  dependent  upon  the  amount  of  shorten- 
ing, the  presence  or  absence  of  stiffness  of  the  hip 
joint,  and  the  amount  of  atrophy  or  wasting  of  the 
muscles. 

The  amount  of  Shortening  varies  between  one-half 
inch  and  three  inches,  and  a  certain  amount  of  it  can 
be  compensated  for  by  a  tilting  of  the  spinal  column 
and  the  pelvis  (bony  margin  of  hips),  so  that  the  indi- 
vidual unconsciously  bends  toward  the  shortened  side 
so  as  to  make  both  limbs  of  equal  length. 

58 


In  a  normal  individual  it  is  not  uncommon  to  find 
limbs  of  unequal  length,  this  discrepancy  varying  be- 
tween one-eighth  and  three-quarters  of  an  inch. 

Shortening  can  also  be  compensated  for  by  the  wear- 
ing of  an  insole  or  a  specially  builded  up  shoe. 

ALLIED  CONDITIONS:  Dislocation,  Contusion,  Sprains 
and  laceration  of  the  ligaments  of  the  hip,  all  give 
points  in  common  with  the  above,  and  a  differential 
diagnosis  can  frequently  only  be  made  by  repeated  ex- 
aminations, and  oftentimes  an  anaesthetic  has  to  be 
given  to  absolutely  determine  which  exists,  and  even 
an  X-ray  examination  may  be  the  only  method  of  ob- 
taining early  confirmation ;  however,  after  a  short  lapse, 
the  diagnostic  features  are  generally  positive  enough  to 
prevent  error. 


59 


XIII.     FRACTURE     OF     THE     PATELLA. 


The  PATELLA  (derived  from  "Patella"  which 
means  "A  little  pan")  is  also  called  the  knee-cap  or  the 

knee-pan. 

ANATOMY:  It  is  located  in  front  of  the  knee-joint  and  cov- 
ers same  when  the  extremity  is  straight  ("Extended") 
but  when  the  part  is  bent  ("Flexed")  the  Patella  rides 
on  the  lower  end  of  the  thigh-bone  ("Femur")  ;  hence 
it  is  that  some  Surgeons  claim  that  the  bone  cannot  be 
broken  by  a  fall  upon  the  knee  unless  the  limb  chances 
to  be  in  a  straight  position  at  the  time  the  violence  be 
inflicted. 

Strictly  speaking  it  is  not  a  "bone"  because  made 
up  of  very  thick  cartilaginous  tissue  rather  more  than 
bony  tissue;  this  accounts  for  the  infrequent  occur- 
ence of  the  injury  in  those  under  20  years  of  age  be- 
cause until  that  time,  the  "cartilage"  element  of  bones 
is  in  excess  of  the  "bony"  element. 

It  is  somewhat  triangular  or  pear  shaped,  with  the 
broad  end  uppermost,  and  is  about  2  1/2  inches  or  3 
inches  long,  and  1  1/2  inches  to  2  inches  wide  and 
from  1/2-inch  to  7/8-inch  thick;  the  front  is  smooth 
and  covered  by  very  dense  "Periosteum"  (fibre-like 
tissue  covering  every  bone)  ;  the  under  side  is  in  the 
form  of  two  cup-Hke  depressions  to  fit  into  the  knobbed 
ends  of  the  thigh-bone  (Femur).  The  top  of  the  bone 
is  bound  to  the  four  very  strong  muscles  of  the  front 
of  the  thigh  in  the  form  of  a  united  tendon  (QUAD- 
RICEPS TENDON),  this  being  the  strongest  con- 
joined muscular  band  in  the  body.  The  bottom  of  the 
bone  is  bound  to  a  prominence  on  the  front  of  the 
shin-bone  (Tibia)  by  a  less  strong  tendon  (PATEL- 
LA TENDON),  and  the  sides  are  reinforced  by  thick 
fringes  of  the  above  referred  to  fibre-like  covering 
of  the  bone  ("Periosteum).     (See  Diagram.) 

60 


Hence  it  is  seen  that  structurally,  the  PATELLA 
is  the  keystone  binding  the  thigh  to  the  leg  and  the 
hinge  on  which  considerable  knee  joint  motion  de- 
pends. 

The  TENDONS  mentioned  are  usually  stronger 
than  the  bone,  and  the  latter  breaks  before  they  rup- 
ture ;  of  the  two,  the  weaker  PATELLA  TENDON  is 
the  more  frequently  affected. 
FREQUENCY:  Comparatively  a  rare  fracture,  forming 
from  i  to  2%  of  all  fractures. 

From  80  to  88%  of  cases  are  in  males. 

Generally  occur  in  those  between  30 — 50  years  of 
age;  clinical  curiosities  in  children  for  the  reason  stated 
above. 


Right  patella:  a,  anterior  surface;  b,  posterior  surface. 

CAUSES:  Results  from  DIRECT  VIOLENCE,  as  by  a 
blow  or  fall  directly  on  the  part;  or  by  INDIRECT 
VIOLENCE  AND  MUSCULAR  ACTION,  as  when 
by  tripping  in  an  effort  to  regain  the  balance,  the  knee 
is  suddenly  contracted,  the  TENDONS  are  put  forci- 
bly on  stretch,  and  they  literally  tear  the  bone  asunder. 
This  last  method  is  claimed  by  many  to  be  the  only 
way  in  which  the  fracture  can  occur,  and  it  presup- 
poses sudden  leverage  upon  an  over-bent  knee. 

SYMPTOMS:  A  sudden  "snap"  can  often  be  heard  or  felt 
by  the  patient,  and  at  the  same  time  inability  to  use 
the  knee  is  at  once  apparent;  by  firmly  walking  on 
the  heel,  it  is  possible  with  great  effort  to  go  a  short 
distance,  but  bending  the  joint  is  totally  impossible. 

61 


Aside  from  the  above  characteristic  sign,  there  are 
also  the  usual  symptoms  of  all  fractures,  such  as 
SWELLING;  PAIN  on  PRESSURE  over  the  part; 
CREPITUS  (a  grating  sensation,  often  audible) ;  AB- 
NORMAL MOBILITY  so  that  the  broken  fragments 
can  be  laterally  moved,  oftentimes  being  separated 
an  inch  or  more  by  the  contraction  of  the  TENDONS, 
and  later  by  the  fluid  in  the  joint. 

The  bone  is  oftenest  broken  directly  across  (about 
80%  of  cases)  at  a  point  just  above  the  middle;  occa- 
sionally, the  line  of  cleavage  may  be  multiple  so  that 
there  are  three  or  more  fragments. 

In  no  fracture  is  there  a  greater  involvement  of  small 
blood  vessels  and  by  their  tearing,  much  blood  col- 
lects in  the  joint  (HAEMARTHROSIS)  and  there  is 
also  established  a  severe  SYNOVITIS  due  to  an  ex- 
cess of  normal  joint  (SYNOVIAL)  fluid.  (See  article 
on  SYNOVITIS.) 
TREATMENT:  As  in  all  fractures  the  aim  is  to  REDUCE 
("SET")  and  then  IMMOBILIZE  the  fragments;  this 
is  done  by  either: 

1.  The  NON-OPERATIVE  method. 

2.  The  OPERATIVE  method. 

If  the  first  named  be  adopted,  the  aim  is  to  bring 
the  fragments  together  by  adhesive  plaster  straps  (or 
other  similar  contrivance)  and  then  to  place  the  part 
in  a  Plaster  of  Paris  or  other  form  of  knee-immobiliz- 
ing splint. 

The  other  method  designs  to  coapt  the  fragments 
by  means  of  stitches  ("Sutures")  introduced  between 
the  bony  edges  (silver  wire  fastened  through  drill 
holes)  or  by  heavy  catgut  (or  "Silkworm"  gut)  en- 
circling the  bone  and  penetrating  the  Tendons.  This 
can  either  be  done  under  Cocaine  or  by  "Freezing" 
the  part  (Local  Anaesthesia)  without  the  aid  of  Ether 
or  Chloroform  (General  Anaesthesia). 

62 


The  present  hospital  vogue  in  New  York  is  what  is 
technically  known  as  THE  OPEN  OPERATION 
METHOD  in  which  a  four  inch  incision  is  made  ver- 
tically over  the  bone,  and  it  is  then  united  by  a  few 
sutures  of  silkworm  or  catgut  and  the  joint  placed  on 
a  long  gutter-shaped  tin  or  plaster  splint,  the  super- 
ficial stitches  being  taken  out  in  ten  days,  but  those 
beneath  are  permitted  to  remain  permanently. 

Whatever  the  method,  heavy  splints  are  worn  four 
or  five  weeks  and  then  removed,  and  massage  and  grad- 
ual motion  of  the  knee  instituted ;  for  six  or  seven 
weeks,  or  longer,  a  light  splint  (or  heavy  leather  sup- 
port) is  used  to  prevent  undue  strain.  Many  persons 
wear  a  knee-cap  for  months,  but  this  is  often  more  of  a 
reminder  than  a  necessity. 

RESULTS:  The  knee  is  always  stiff  (ANCHYLOSIS),  but 
usually  by  the  ioth  or  12th  week  it  can  be  bent  to  a 
right  angle,  the  limit  of  bending  being  the  measure  of 
function ;  this  degree  of  restoration  meets  all  prac- 
tical purposes,  but  in  ascending  and  descending,  a 
LIMP  or  other  DISABILITY  is  apparent. 

By  continued  use,  and  often  by  forced  bending  (un- 
der an  anaesthetic)  nearly  full  function  is  restored. 

Occasionally  the  extremity  cannot  be  fully  straight- 
ened (EXTENSION  LIMITED),  but  this  does  not 
rob  the  part  of  function  and  its  disappearance  keeps 
pace  with  that  of  the  damaged  bending  power  (FLEX- 
ION LIMITED.) 

The  muscles  of  thigh  and  leg  are  wasted  (ATRO- 
PHIED) from  the  long  disuse,  but  if  massage  be  given 
early,  and  the  joint  be  promptly  used,  this  soon  disap- 
pears. 

In  no  bone  is  FIBROUS  rather  than  BONY-union 
more  usual,  but  even  with  the  presence  of  the  former, 
and  a  wide  separation  of  the  fragments,  a  functionally 
active  knee  is  the  rule. 

63 


In  this,  more  than  any  other  bone,  refractnre  is 
liable  unless  care  is  taken;  but  it  is  most  imminent 
within  the  first  six  weeks  after  the  splints  are  removed. 
If  it  occurs,  the  line  of  cleavage  is  generally  at  the 
original  site,  this  being  because  of  the  non-bony  struc- 
ture of  the  Patella  (and  hence  the  lack  of  the  usual 
bony  CALLUS),  but  mainly  because  fibre  rather  than 
bone  so  often  unites  the  fragments. 


64 


XIV.     POTTS'    FRACTURE. 


This  fracture  is  commonly  referred  to  as  "the  frac- 
ture of  the  ankle  joint,"  and  it  receives  its  name  be- 
cause it  was  first  described  by  a  Dr.  Pott,  of  England. 

ANATOMY:  The  lower  ends  of  the  leg  bones  join  a  bone  of 
the  foot  (ASTRAGALUS)  to  form  the  ANKLE 
JOINT. 

The  outer  leg  bone  (called  the  FIBULA)  and  the 
inner  leg  bone  (called  the  TIBIA)  end  below  in  prom- 
inent flanges  called,  respectively,  the  EXTERNAL 
MALLEOLUS  and  the  INTERNAL  MALLEOLUS; 
these  can  be  felt  at  the  margins  of  the  ankle  and  are 


Pott's    fracture,    showing    the    characteristic    outward    and    backward 
deformity. 

visible  even  through  the  shoes.  They  are  the  ana- 
logues of  the  margins  of  the  forearm  bones  at  the 
wrist.     {See  Diagram.) 

These  MALLEOLI  are  bound  to  a  square  shaped 
bone  of  the  foot  (called  the  ASTRAGULUS)  by 
strong  ligaments,  that  on  the  outside  being  known  as 
the  EXTERNAL  LATERAL  LIGAMENT;  that  on 


65 


7*»»4 


Bones  of  the  right  leg, 
anterior  surface. 


Bones  of  the  right  leg, 
posterior  surface. 


66 


the  inside,  being  the  INTERNAL  LATERAL  LIG- 
AMENT; there  is  also  another  ligament  that  holds 
these  parts  transversely,  this  being  the  INTEROS- 
SEOUS LIGAMENT. 

This  fractuYe  (according  to  the  recognized  classi- 
fication of  Stimson)  involves  : — 

(i)  A  break  of  the  outer  bone  (Fibula)  about 
three  inches  above  its  lower  tip ; 

(2)  A  break  of  the  lowest  tip  of  the  inner 
bone  (Tibia)  ; 

(3)  A  chipping  of  the  small  prominence  on 
the  lower  outer  margin  of  the  inner  bone 
(Tibia)  ;  and 

(4)  A  tearing  of  the  Internal  Lateral  and 
Interosseous  Ligaments. 

It  is  thus  seen  that  there  are  three  lines  of  bony 
injury  and  two  torn  ligaments.  With  the  above,  and 
because  the  normal  relations  are  so  much  disturbed, 
there  is  an  outward  and  backward  deviation  of  the 
entire  foot,  this  making  the  deformity  so  character- 
istic as  to  be  instantly  recognized.    (See  Diagram.) 

The  essential  point  in  the  fracture  (however  much) 
it  may  be  modified  from  the  above)  is  the  separation 
of  the  outer  flange  (External  Malleolus)  from  the  inner 
bone  (Tibia)  and  the  outward  and  backward  distor- 
tion of  the  entire  foot. 

Various  authorities  modify  the  elements  of  the  frac- 
ture, but  the  above  is  the  standard  employed  in  local 
Hospitals  and  Medical  Colleges. 

SYMPTOMS:  As  has  been  stated,  the  immediate  deformity 
is  typical  of  this  injury  alone,  and  with  it  is  associated 
much  swelling,  pain,  and  total  abolition  of  function 
so  that  it  is  impossible  to  bear  unsupported  weight  on 
the  injured  part.  Later,  discoloration  is  extensive. 
The  other  corroborative  signs  of  fracture  are  also  pres- 

67 


ent,  such  as  Crepitus  (grating)  and  unusual  lateral  mo- 
tion. 

TREATMENT:  The  essentials  of  treatment  are:  First,  the 
reduction  or  setting  of  the  fracture,  this  not  infre- 
quently requiring  the  aid  of  an  anaesthetic  to  over- 
come the  above-mentioned  deforming  dislocation. 

After  this  is  entirely  overcome,  the  part  is  put  in 
a  temporary  splint  (  made  of  tin  or  wood)  and  ice-bags 
or  other  applications  placed  about  the  extremity  to 
reduce  the  swelling. 

Later — within  a  week  or  ten  days — a  Plaster  of 
Paris  apparatus  is  applied,  with  the  foot  sharply  bent 
upward  and  inward;  and  this  is  allowed  to  remain  in 
place  for  about  two  weeks,  the  patient  preferably  being 
on  a  couch  or  big  chair.  The  apparatus  is  then  removed 
and  re-applied.  If  the  swelling  decreases  before  this 
interval,  the  Cast  then  becomes  loose  and  requires  earl- 
ier replacement.  At  the  end  of  from  four  to  six  weeks 
all  apparatus  is  removed  except  a  snug  muslin  band- 
age, and  massage,  gradual  motion  and  use  of  the  part 
'is  insisted  upon.  Firm  union  of  the  broken  bones  is 
usually  complete  in  about  four  weeks,  and  thereafter 
the  greater  use  that  is  made  of  the  part  the  earlier  and 
speedier  will  be  the  recovery. 

It  is  important  that  an  old  person  be  not  allowed  to 
remain  in  bed  because  of  threatened  stagnation  of  cir- 
culation through  the  heart,  lungs  and  kidneys. 

RESULTS:  If  the  original  deformity  be  not  reduced  and  the 
fracture  be  not  properly  set,  a  permanently  stiff  and 
greatly  deformed  joint  will  ensue.  If  the  apparatus 
be  permitted  to  remain  longer  than  four  weeks  without 
removal,  or  if  it  bo  retained  for  a  period  of  more  than 
six  weeks,  then  some  permanent  stiffness  (ANCHY- 
LOSIS) of  the  ankle  is  sure  to  result  from  the  more  or 
less   wasting   (ATROPHY)    of  the   leg   muscles.     In 

68 


persons  over  45  years  of  age  a  somewhat  damaged 
joint  is  reasonably  sure,  this  taking  the  form  of  swell- 
ing, some  tenderness,  and  inability  to  fully  bend  the 
ankle.  A  certain  amount  of  pain  is  usually  present 
for  some  time,  especially  after  exercise  and  following 
changes  of  the  weather. 

At  the  end  of  from  six  to  eight  weeks  the  patient 
is  usually  able  to  walk  with  the  aid  of  a  crutch  or  cane, 
and  in  about  three  months  is  able  to  go  to  work. 

There  are  certain  exceptional  cases  in  which  the 
above  period  of  treatment  may  be  shortened  or  length- 
ened because  of  associated  or  unusual  conditions;  but 
even  an  extensively  deformed  ankle  may  permit  of 
almost  perfect  function. 


69 


XV.     FRACTURE     OF     THE     SKULL. 


ANATOMY:  The  Skull  is  a  bony  cage  made  up  of  the 
Cranium  (which  means  a  helmet)  and  the  Face,  com- 
prising 22  separate  bones;  but  for  all  practical  pur- 
poses the  Skull  is  that  portion  exclusive  of  the  face, 
made  up  of  8  bones. 

These  bones  are  closely  mortised  to  each  other  much 
in  the  same  manner  as  would  be  the  interlocked 
fingers,  the  line  of  junction  being  saw-tooth-like ;  these 
lines  of  union  are  known  as  SUTURES,  and  in  early 
life  they  are  unjoined  to  permit  of  expansion  of  the 
brain,  and  even  in  adults  they  are  capable  of  consid- 
erable motility,  this  being  a  provision  of  Nature  to 
overcome  the  effects  of  violence. 

Each  bone  of  the  Cranium  has  three  layers  (or 
tables),  an  Outer,  Middle,  and  Inner. 

The  Outer  Layer  or  Table  is  thick  and  tough 
and  very  resistant.  Attached  to  it  is  the  Peri- 
osteum, or  fibrous  membrane  that  covers  every 
bone. 

The  Middle  Layer  is  soft,  meshed  like  a 
sponge  and  designed  to  carry  blood-vessels  and 
act  as  a  bumper  between  the  outside  and  inside 
layers. 

The  Inner  Layer  is  also    hard,  and    it    is 
grooved  to  permit  the  passage  of  large  blood- 
vessels. 
The   Brain   proper  is  also  covered  by  three  mem- 
branes (called  Dura  Mater,  Pia  Mater  and  Arachnoid), 
and  between  the  outside  layer  of  the  Brain  and  the 
inner  layer  of  Skull  is  a  layer  of  fluid,  the  Cerebro- 
spinal fluid,  this  extending  into  the  spinal  cord  by  a 
hole  in  the  bottom  of  the  skull. 

Hence  it  can  be  seen  that  the  contents  of  the  skull 
are  well  protected  by  thick  bones  (that  yield  somewhat 

70 


to  pressure),  by  a  bumper  of  water,  and  by  a  fibrous 
network  on  the  inside  of  the  skull  and  the  outside  of 
the  brain. 

The  bone  at  the  back  of  the  head  (Occipital  bone) 
is  the  strongest  of  the  skull,  that  of  the  forehead  is 
next  in  thickness  (Frontal  bone)  and  those  at  the  side 
of  skull  (Parietal  bones)  are  the  thinnest;  the  densest 
and  hardest  section  of  the  entire  region  is  that  promi- 
nence just  back  of  the  ear  known  as  the  "Mastoid 
Process." 

The  danger  of  a  skull-injury  depends  in  large  meas- 
ure upon  the  site  of  the  infliction  of  the  violence  for 
the  reason  that  all  portions  of  the  underlying  brain 
do  not  perform  equally  important  functions;  for  ex- 
ample, a  blow  on  the  back  of  the  head  would  need  to 
be  given  with  much  force  before  that  section  of  bone 
would  fracture,  and  further,  this  portion  of  the  brain 
could  stand  considerable  insult  without  appreciable 
effect.  But  if  a  fracture  were  to  occur  in  the  vicinity 
of  a  line  joining  the  tops  of  the  ears,  running  over  the 
crown  of  the  head,  serious  effect  could  result  from 
lesser  violence  and  the  damage  might  be  greater  be- 
cause of  the  important  underlying  functionating  seg- 
ment of  the  brain. 

It  has  been  well  said  that  the  Brain  is  comparable 
to  a  Hotel  in  which  some  rooms  are  furnished,  occu- 
pied and  doing  work ;  others  are  idle  and  of  no  proved 
value.  The  brain  has  been  divided  into  "rooms," 
many  of  them  occupied  (called  "Centers"),  some  of 
them  unoccupied,  and  if  the  latter,  then  that  section  is 
referred  to  as  a  "Silent  Area  of  the  Brain."  These 
have  been  accurately  located  by  repeated  animal  ex- 
perimentation, and  also  by  observation  in  cases  of 
severe  head  injury  in  which  portions  of  the  brain  have 
been  pulpified  and  even  scooped  out;  and,  further, 
where   at   autopsy   or   on   the   operating   table,   large 


71 


growths    have    been    found    instead    of    normal    brain 
tissue,  the  symptoms  in  life  not  pointing  to  any  such 

possibility. 

TYPES   OF   FRACTURE:    These   depend   on   the    (a)    Site 
and  (b)  Degree  of  the  fracture. 

(a)  The  Site  is  arbitrarily  determined  by  an  imagi- 
nary line  that  passes  backward  from  the  outer  border 
of  the  eye-socket,  to  the  exit  of  the  ear,  to  the  promi- 
nence of  the  back  of  head  ("External  Occipital 
Protuberance"),  and  thence  to  the  starting  point. 

Any  fracture  above  this  line  is  called  a  Fracture  of 
the  Vault,  and  any  fracture  below  is  known  as  a 
Fracture  of  the  Base  of  the  Skull. 

(b)  The  Degree  is  determined  by  the  amount  and 
sort  of  violence,  and  we  may  have  the  following  va- 
rieties of  Fractured  Skull : 

Simple,  in  which  there  is  a  crack  or  crevice 
without  breaking  of  the  skin. 

Compound,  in  which  there  is  a  crack  or 
crevice  with  breaking  of  the  skin  leading  to 
the  fracture-site. 

Depressed,  in  which  the  bone  is  dented  or 
pushed  in,  either  without  (Simple)  or  with 
(Compound)  a  break  in  the  skin. 

Comminuted,  in  which  there  is  fragmentation 
of  the  bone,  either  Simple  or  Compound. 

Linear,   in  which   there  is  a   line-like   crack, 
either  Simple  or  Compound. 
CAUSES:     Always  due  to   (a)   Direct  or   (b)   Indirect  Vio- 
lence. 

(a)  Direct   Violence    means   that  the   impact 

has  been  delivered  directly  over  the 
fracture-site,  as  by  a  fall,  or  blow  with 
a  hammer. 

(b)  Indirect   Violence   implies  that  the  force 

has  been  transmitted  from  a  distance, 


as  by  a  fall  on  the  feet  or  buttocks  ; 
this  form  is  rare. 

SYMPTOMS:  These  depend  on  the  Site,  Degree  and  Extent 
of  the  fracture,  and  somewhat  on  the  age  and  general 
physique  of  the  individual. 

FRACTURES  OF  THE  VAULT:  If  the  fracture  be  of  the 
Simple  variety  with  a  mere  crack  or  small  dent  in  the 
skull,  there  will  be  no  symptoms  aside  from  those  of 
bruises  or  wounds  near  the  part  involved ;  this  is  espe- 
cially true  if  the  fracture  involve  only  one  layer  of  the 
skull — almost  always  the  outer — being  then  known  as 
a  fracture  of  the  External  (Outer)  Table  of  the  Skull. 

If  the  skull  be  Depressed,  the  symptoms  will  de- 
pend on  the  site  of  the  break  and  the  amount  of 
pressure  due  to  the  driven-in  fragment ;  some  sections 
of  the  brain  (as  stated  above)  are  little  affected  by 
considerable  pressure,  but  others  give  characteristic 
signs  which  are  too  diverse  for  mention. 

The  entire  outcome  of  the  fracture  depends  on  the 
degree  of  pressure  symptoms,  or,  in  other  words,  upon 
the  extent  of  brain-involvement ;  there  may  be  fracture- 
lines  enough  on  the  skull  to  suggest  a  cracked  egg- 
shell, but  if  these  are  not  depressed  sufficiently  to 
cause  pressure,  and  if  there  has  been  no  bleeding  to 
act  likewise,  then  the  effects  are  those  of  Concussion, 
plus  the  swelling,  discoloration  and  bleeding  of  an  as- 
sociated Contusion  or  Laceration  of  the  Scalp. 

In  some  instances  a  Haematoma  (circumscribed 
contusion,  or  "blood-blister")  is  mistaken  for  a  de- 
pressed fracture  of  the  skull,  and  the  error  is  fre- 
quently undiscovered  until  the  scalp  is  opened ;  if  the 
diagnosed  depression  has  been  large,  and  if  it  disap- 
pears after  the  swelling  subsides  (without  operation), 
there  of  course  has  been  no  injury  except  to  the  soft 
parts. 

73 


If  the  fracture  be  of  the  "Compound"  type,  the  as- 
sociated wound  receives  the  same  treatment  as  would 


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AjiUrier  CllasU  rrr, 

XulJU  CluunJi  jprrx 
fmtUrirr  CliiviH  frea 

Cretn-  f,r  6* 
TtrS  lajerum  nudium. 
CrifU*  ./  CutU  Canal 
Pspnuim  ttr  Ca*nrma  Caelum 


2f**tut  Auditor.  Ixtmiu- 

Slit  f*r  Uura-ATattr 
*5Vp.  PdtrrtAl  g 


F  "■   l*cmm  »*iu 
A-Utrier  Cc+iylout  Fo* 
Aqutduet.  Vttt\bt*h 
Ytttrrlcr  CmJyUvl  Fm 


Afajtaid  Jrt. 


Base  of  the  skull,  inner  or  cerebral  surface  (Gray),  showing  the  An- 
terior, Middle  and  Posterior  Fossa. 

a  wound  in  any  other  location ;  the  danger  in  such  an 
instance  is  the  possibility  of  infection   (poisoning)  of 


74 


the  wound  by  germs  which  might  traverse  the  frac- 
ture-line and  cause  involvement  of  the  brain-coverings 
(Meningitis),  and  later  damage  the  brain  tissue  enough 
to  produce  Abscess  of  the  Brain.  Complications  of 
this  sort  are,  however,  rare  and  very  remote  under 
proper  surgical  care. 

Children  stand  head-injury  much  better  than  adults 
because  their  bones  are  more  elastic. 

FRACTURES  OF  THE  BASE:  These  may  occur  as  the 
primary  injury,  or  be  associated  with  a  fracture  of 
the  vault,  and  vice  versa. 

The  base  of  the  skull  is  divided  into  three  shallow 
basins,  called  respectively  the  ANTERIOR,  MIDDLE 
and  POSTERIOR  BASIN,  or  FOSSA,  and  from  each 
fossa  there  are  certain  openings  leading  to  the  ex- 
ternal air.     {See  Diagram.) 

The  symptoms  depend,  to  a  considerable  degree,  on 
which  fossa  is  broken,  but  in  a  general  way,  a  frac- 
tured base  of  the  skull  will  present  some  or  all  of  the 
following : 

Concussion     symptoms,     especially     uncon- 
sciousness; 

Bleeding  from  the  nostril  or  nostrils,  from 
the  mouth,  from  the  ear  or  ears,  and  "blood- 
shot" eyes  ("Subconjunctival  haemorrhage")  ; 
Changes  in  the  pulse  and  respiration. 
If  the  brain  itself  be  involved,  or  if  bony  or  bloody 
pressure  be  present  (as  by  a  clot),  there  may  be: 
Paralyses  of  groups  of  muscles; 
Deviation  of  the  eyes; 
Changes  in  the  reflexes ; 
Impaired  control  of  bowels  and  bladder; 
Convulsions. 
The  cardinal  signs  of  "fractured  base"  are : 

Unconsciousness,    and    bleeding     from     the 
nostril  or  ear  or  mouth  or  into  the  eyeball. 

75 


What  has  been  said  regarding  each  type  of  frac- 
tured skull  applies  universally;  viz.,  unless  there  is 
pressure  on  the  brain  (by  bony  fragments  or  blood 
clot),  the  broken  bone  is  of  little  importance.  It  was 
formerly  considered  mortal  to  sustain  a  fracture  of  the 
skull,  especially  a  basal  fracture,  but  there  are  count- 
less cases  of  even  extensive  depression  with  marked 
signs  of  brain  injury  in  which  perfect  recovery  has 
occurred. 

TREATMENT:  The  rule  is,  "Do  nothing  radical  unless  there 
is  pressure  enough  to  give  symptoms,"  then  relieve  the 
pressure  by  operation  which  trephines  over  the  pres- 
sure-site, elevates  depressed  bone,  removes  blood- 
clots,  or  otherwise  meets  the  emergency  by  appropriate 
surgical  means. 

Fractured  base  of  the  skull  is  inaccessible  to  surgical 
methods,  and  all  that  is  aimed  at  is  the  disinfection 
(by  mild  antiseptics)  of  the  bleeding  zones  (eye, 
mouth,  ear  or  nose)  ;  if  symptoms  arise  pointing  to 
brain  involvement,  subsequent  steps  are  determined 
by  the  individual  signs  prsented. 

RESULTS:  The  usual  linear  simple  fracture  of  the  Vault 
makes  a  complete  recovery  within  a  short  time,  but 
it  must  be  remembered  that  such  a  condition  cannot 
be  positively  diagnosed  unless  the  scalp  be  incised ; 
hence  nearly  all  skull-fractures  are  originally  "com- 
pound" in  type  or  are  made  so  by  the  Surgeon. 

The  Compound  type  differs  from  the  above  only  in 
the  presence  of  the  wound,  and  if  healing  in  it  is 
prompt,  the  scar  is  the  sole  remnant  in  the  majority 
of  cases. 

The  Depressed  fracture  becomes  of  importance  if 
thereby  pressure  is  induced  in  a  functionating  location; 
if  the  pressure  be  promptly  relieved,  and  if  the  brain 

76 


tissue  has  been  uninvolved,  and  if  the  brain-coverings 
do  not  become  adherent,  recovery  is  the  rule.  The  in- 
dividual usually  carries  a  scar  and  has  a  hole  in  the 
cranium  to  mark  the  site  where  the  trephine  was  ap- 
plied;  such  a  defect  (if  small)  is  sometimes  filled  in  by 
new  bone,  otherwise  a  special  plate  can  be  inserted. 
There  are  many  persons  who  have  had  a  very  extensive 
removal  of  bone,  and  in  whom  the  brain  can  be  seen 
to  pulsate  through  the  skin  covering  the  bony  defect, 
and  despite  this  apparent  structural  damage,  they 
have  perfect  mental  power. 

BASAL  FRACTURE  is  a  serious  condition  because  the  brain 
or  its  coverings  are  so  often  affected.  In  this  location 
are  the  "Twelve  Pairs  of  Cranial  Nerves"  controlling 
the  special  senses  and  facial  expression,  and  some  of 
them  are  frequently  involved,  especially  the  nerves  of 
the  eyes  and  ears. 

Bleeding  from  one  orifice  (as  an  ear)  is  usually  an 
indication  of  a  fracture  without  much  associated  brain- 
damage  and  complete  restoration  is  probable,  even 
though  the  ear-drum  has  been  extensively  torn. 

It  has  been  said  that  if  the  patient  survive  twenty- 
four  hours,  his  chances  are  good. 

It  is  not  uncommon  for  persistent  special-sense  de- 
fects to  occur,  these  commonly  taking  the  form  of 
deafness,  impaired  or  distorted  vision  and  perverted 
taste  and  smell ;  occasionally  also  there  will  be  paraly- 
sis of  groups  of  muscles,  as  of  the  face  or  an  extremity. 

There  are  occasionally  after-effects  in  the  form  of 
Epilepsy,  Memory  Defects,  Gait-unsteadiness,  Eye  and 
Ear  difficulty,  and  Diminution  of  Muscular  Power — 
but  in  every  such  instance,  there  has  been  some  as- 
sociated injury  to  the  brain  or  its  coverings. 

A  well-known  authority  (Phelps'  "Traumatic  In- 
juries of  the  Brain")  says  that  of  245  cases  of  frac- 
tured base,  only  six  showed  involvement  of  the  optic 

77 


nerve,  and  that  if  the  nerves  of  the  eye  are  to  be  af- 
fected, signs  thereof  occur  within  the  first  two  weeks. 

This  same  author  also  says  that  the  callus  (Nature's 
reparative  solder)  following  linear  fracture  is  very 
slight,  and  in  fractured  base,  persistent  callus  is  prac- 
tically unknown ;  hence  it  is  specious  to  claim  after- 
effects from  the  pressure  of  such  a  substance. 

As  to  fractured  base  he  says  that  approximately 
36  per  cent,  of  the  286  cases  reported  made  a  good  re- 
covery, and  many  of  these  were  gunshot  wounds  and 
very  severe  falls  (from  scaffolds,  into  holds  of  steam- 
ers, down  stairs,  from  windows,  etc.),  and  if  the  cases 
due  to  such  great  violence  were  excluded,  he  estimates 
that  approximately  50  per  cent,  would  recover. 

There  are  frequently  many  subjective  symptoms 
claimed  such  as  buzzing  in  the  ears,  spots  before  the 
eyes,  dizziness,  headache,  unsteadiness  in  gait  (espe- 
cially when  at  a  height  or  in  ascending  or  descending), 
nausea,  and  diminished  mental  aptitude.  Some  of 
these  are  natural  sequels,  but  if  unassociated  with  ob- 
jective findings,  and  if  not  borne  out  by  the  person 
when  apparently  unobserved,  they  are  assumed  or  a 
part  of  a  neurasthenic  condition. 

SUMMATION:  Fractures  of  the  skull,  per  se,  are  unimpor- 
tant, and  they  become  dangerous  and  permanently 
damaging  only  when  there  has  been  associated  injury 
to  the  brain  by  pressure  (depressed  fragments  of  bone, 
or  blood  clot)  or  by  actual  laceration  or  destruction 
of  its  tissue.  In  fracture  of  the  Vault,  these  sequelae 
are  infrequent ;  in  fracture  of  the  Base  they  are  com- 
mon, but  not  to  the  extent  formerly  believed  as  sta- 
tistics show  that  from  36  to  50  per  cent,  of  such  cases 
recover. 

The  possibility  of  remote  after  effects  (of  which 
Traumatic  Epilepsy,  Memory  and  Eye  and  Ear  De- 
fects are  types)  depend  in  great  measure  on  the  in- 

78 


itial  variety,  location  and  severity  of  the  fracture,  and 
if  signs  of  structural  involvement  are  lacking  after 
the  stage  of  convalescence,  subsequent  symptoms  may 
or  may  not  be  attributable  to  the  original  trauma,  and 
differentiation  must  be  made  with  great  care  and 
only  after  rigid  examination. 


79 


XVI.     DISLOCATIONS 


A  dislocation  is  the  separation  of  the  ends  of  the  bones  en- 
tering into  the  formation  of  a  joint.  The  condition  is  some- 
times called  a  "Luxation." 

All  dislocations  are  attended  by  a  tearing  of  the  ligaments 
about  the  joint  and  synovitis  (excessive  fluid  in  a  joint). 
CLASSES: 

Simple  Dislocation  is  where  the  bones  are  merely 
out  of  place  without  the  presence  of  a  wound. 
Also  called  a  "closed"  dislocation. 
Compound  Dislocation  is  where  the  bones  are 
out  of  place  with  the  presence  of  a  wound;  this 
class  is  very  rare  and  is  usually  associated  with  a 
fracture.  Also  called  an  "open"  dislocation. 
Partial  or  Incomplete  Dislocation  or  Sub-luxation 
is  where  the  bones  are  but  partly  displaced  and 
spontaneously  or  easily  resume  their  normal  posi- 
tion. This  is  the  classification  of  the  older  Sur- 
geons, and  is  not  given  much  prominence  to-day. 
FREQUENCY:  Comparatively  common,  but  only  one-tenth 
as  common  as  Fractures. 


A. 


B. 


C. 


The  commonest  form  of  Dislocation  of  Shoulder  ("Subcoracoid  Dis- 
location)." 

The  shoulder  is  most  frequently  dislocated,  forming 


80 


from  one-third  to  two-thirds  of  all  dislocations.    Next 
in  frequency  are  the  elbow  and  ankle.     (Sec  Diagram.') 

CAUSATION:  Some  persons  have  a  normal  "Dislocation 
Tendency"  from  their  conformation  ("Loose-jointed"), 
or  from  previous  inflammation  of  a  joint. 

The  ordinary  causes  are:  External  violence,  as  by 
a  fall  directly  on  the  joint;  or  muscular  action,  as  in 
pitching  a  ball,  thus  "throwing  the  shoulder  out  of 
joint." 

TREATMENT:  Can  be  summed  up  by  the  three  "indica- 
tions" : 

1.  Reduce  or  "Set"  the  dislocation;  this  is 
done  by  pulling  on  the  parts  or  by  special 
manipulation. 

2.  Immobilize  it  by  bandages  or  apparatus. 

3.  Massage  and  gradual  motion  after  a  short 
time. 

If  a  wound  be  present,  it  is  treated  on  gen- 
eral principles.    After  the  dislocation  has  been 
"set,"   the   injury  practically  becomes   similar 
to  a  lacerated  ligament  with  Synovitis   (fluid 
in  joint). 
RESULTS:     When  the  bandages    are    removed,  a    certain 
amount  of  ATROPHY    (wasting)    has  occurred  be- 
cause of  the  disuse.     This  results  even  when  an  un- 
injured part  has  been  kept  idle  for  a  similar  period, 
and  hence  is  not  due  directly  to  the  injury  itself. 

The  joint  is  more  or  less  stiff  and  full  use  of  it  can 
not  be  made ;  and,  if  bandages  have  been  employed 
longer  than  the  requisite  period,  a  certain  amount  of 
ANCHYLOSIS  (anchoring  or  fixation)  may  be  pres- 
ent so  that  motion  is  interfered  with  to  a  considerable 
degree. 

This  may  be  either  FIBROUS  ANCHYLOSIS, 
where  the  joint  is  bound  by  inelastic  bands  of  fibre; 
or   BONY  ANCHYLOSIS,  where  the  bones  of  the, 

81 


joint  are  firmly  bound  together  by  bony  tissue.     (This 
is  rare.) 

FIBROUS  ANCHYLOSIS  is  overcome  by  massage 
and  use,  and  generally  leaves  no  permanency. 

BONY  ANCHYLOSIS  is  remediable  to  some  de- 
gree by  operation,  but  some  permanent  disability  or 
deformity  is  invariable. 
DISABILITY :  This  depends  upon  the  site  of  the  disloca- 
tion, its  type  (simple  or  compound),  and  the  method 
of  treatment  (especially  as  to  the  time  the  dislocation 
is  set  and  the  period  of  bandaging),  and  on  the  in- 
dividual. 

In  a  general  way  idleness  should  not  extend  over 
six  weeks,  but  if  ANCHYLOSIS  be  present,  this  is 
more  or  less  lengthened. 


82 


XVII.     STIFF     JOINTS. 


Such  a  condition  is  technically  known  as  ankylosis  (some- 
times spelled  anchylosis),  and  by  it  is  implied  either  partial 
or  complete  limitation  of  normal  joint  motion. 

There  are  two  sorts  of  stiff  joints  as  to  manifestation : 

i.  Fibrous  stiffness,  or  "False"  ankylosis,  or  adhe- 
sions ; 

2.  Bony  stiffness,  or  "True"  ankylosis,  or  adhes- 
sions, 

FIBROUS  ANKYLOSIS  is  that  due  to  the  joining  together 
of  the  joint  surfaces  by  more  or  less  elastic  bands  of 
fibre,  either  in  the  form  of  individual  strands  or  as  a 
diffused  network  of  "adhesions." 

This  form  of  ankylosis  occurs  most  commonly  after 
fractures,  dislocations,  sprains,  synovitis  and  inflam- 
matory conditions  of  the  interior  of  the  joint;  and  also 
from  disuse  consequent  upon  the  foregoing  or  bad 
treatment. 

BONY  ANKYLOSIS  is  less  common  than  the  above,  and  is 
the  joining  together  of  the  joint  surfaces  by  bony  tis- 
sue. It  is  usually  an  accompaniment  of  severe  or  com- 
pound joint-fractures,  and  implies  that  the  normal  carti- 
lagious  covering  of  the  ends  of  the  bones  has  been  de- 
stroyed, and  thus  the  irregular  exposed  bony  surfaces 
glue  together.  New  bony  tissue  is  then  interposed, 
the  process  of  formation  being  not  unlike  the  healing  of 
a  broken  bone  by  callus. 

This  form  of  ankylosis  only  follows  if  the  ends  of 
the  bones  have  been  denuded,  and  hence  there  is  noth- 
ing in  the  form  of  cartilage  separating  the  apposing 
surfaces  to  prevent  bony  bands  from  interposing. 

ANATOMY: 

Roughly  speaking,  all  joints  are  of  two  varieties : 
I.     HINGE  JOINTS,  as  the  elbow  and  ankle ; 

83 


2.  BALL  AND  SOCKET  JOINTS,  as  the  shoulder 
and  hip. 

In  the  first  variety,  there  is  practically  only  a  forward  and 
backward,  or  up  and  down  motion.  In  the  second,  there  is 
the  hinge  action,  but  in  addition,  rotation. 

The  ends  of  the  bones  forming  the  joint  are  capped  by  a 
layer  of  cartilage  for  ease  of  motion,  affording  an  elastic 
smooth  wearing  buffer  surface. 

Within  the  joint  cavity  (which  is  usually  air  tight),  there 
is  a  lining  of  thin  fibre  called  the  SYNOVIAL  MEMBRANE, 
which  secretes  an  oily  substance  acting  as  a  lubricant,  this  be- 
ing called  SYNOVIAL  FLUID.  When  this  membrane  be- 
comes inrlammed  or  irritated,  the  secretion  increases,  the  fluid 
accumulates,  and  SYNOVITIS  ensues;  every  membrane  in 
the  body  acts  in  an  identical  manner,  a  "Cold  in  the  head"  be- 
ing an  apt  illustration  of  increased  secretion  from  an  irritated 
surface. 

All  the  joints  are  richly  supplied  with  a  network  of  blood 
vessels,  and  in  some  deep  seated  joint  injuries  (most  commonly 
in  the  knee),  these  vessels  break,  blood  accumulates  and  mix- 
es with  the  SYNOVIAL  FLUID,  and  we  have  what  is  tech- 
nically known  as  HAEMORRHAGIC  SYNOVITIS;  this  is 
also  sometimes  called  HAEMARTHROSIS. 

INJURIES  CAUSING  ANKYLOSIS, 
i.     Contusions; 

2.  Sprains; 

3.  Dislocations; 

4.  Fractures. 

CONTUSIONS  must  be  exceedingly  severe  in  order  to  pro- 
duce a  joint  stiffness,  and  the  latter  results  therefrom 
either  by  direct  injury  to  the  joint  surfaces,  resulting 
in  SYNOVITIS,  or  from  disuse  of  the  part  due  to  pro- 
longed bandaging  or  splinting. 

In  such  a  case  there  will  be  external  evidences  in  the 
form  of  discoloration  or  swelling  about  the  soft  parts 

84 


near  the  joint,  and,  in  addition,  the  accompanying  signs 
of  SYNOVITIS  (see  article  on  this  topic).  The  accu- 
mulated synovial  fluid  is  absorbed,  or  otherwise 
removed,  or  some  of  it  may  remain  and  become  con- 
verted into  fibre-like  tissue,  binding  together  the  joint 
surfaces  as  by  a  strong  network  of  threads.  The  longer 
the  part  is  kept  immovable,  the  tighter  and  stronger 
will  these  bands  become,  and  in  time  (if  untreated)  the 
gluing  becomes  so  firm  as  to  be  almost  unbreakable. 

STRAINS  act  in  an  identical  manner  to  the  above,  but  the 
effect  is  usually  more  severe. 

DISLOCATIONS  act  as  do  the  foregoing  but  to  an  advanced 
degree,  because  there  is  a  tear  in  the  capsule  about 
the  joint  in  every  dislocation,  and  this  adds  to  the  in- 
flammatory reaction  within  the  joint.  The  amount  of 
resulting  stiffness  is  also  greater  because  of  the  neces- 
sarily longer  period  of  bandaging  or  immobilizing. 

FRACTURES  act  mainly  because  the  prolonged  disuse  of 
the  involved  part  lessens  the  normal  secretion  of  the 
synovial  fluid,  the  joint  is  improperly  lubricated,  and 
ceases  to  do  its  normal  work  when  called  upon  after 
a  period  of  inactivity;  joints  are  like  any  hinge  that 
gets  rusty  from  lack  of  use. 

DIAGNOSIS. 

Granting  that  any  of  the  above  four  named  injuries  have 
occured  with  the  accompanying  disuse,  there  are  certain  cor- 
roborative evidences  of  an  alleged  inability  to  move  a  joint, 
and  of  these  the  most  important  are : 

i.  ATROPHY  or  wasting  of  the  muscles  that  nor- 
mally move  the  joint; 

2.  FLABBINESS  of  the  muscles ; 

3.  INABILITY  TO  ROTATE  or  otherwise  move  one 
or  both  of  the  bones  entering  into  the  formation  of 
the  joint; 

85 


4.     INABILITY  TO  CONTRACT  the  muscles  about 
the  involved  joint,  because  of  their  lessened  power. 

The  extent  of  the  above  quartet  of  signs  depends  on 
the  location,  nature  and  treatment  of  the  original  in- 
jury, but  within  six  weeks  a  disabled  joint  will  show 
most  or  all  of  these  corroborative  evidences. 

ATROPHY  (or  wasting)  is  the  cardinal  indication  that  the 
part  has  not  been  used,  for  the  muscle  tissue  is  the  mot- 
ive power,  and  it  is  an  invariable  rule  of  Nature  that 
an  idle  part  or  organ  shrinks  and  finally  becomes  use- 
less or  disappears.  This  wasting  is  directly  proportion- 
ate to  the  amount  of  stiffness  and  disuse  existing  and 
affects  the  muscles  normally  operating  the  joint  to  the 
extent  of  producing  a  visible  or  measurable  diminu- 
tion, or  both. 

FLABBINESS  is  the  accompaniment  of  the  wasting  and  is 
based  on  the  same  causation,  that  is,  lessening  of  tone 
following  inaction. 

INABILITY  to  perfectly  use  the  joint  is  the  sequence  of  the 
above,  and  in  a  part  that  is  genuinely  stiff  or  fixed,  it 
will  be  impossible  to  move  the  separated  joint  surfaces 
without  moving  all  the  bones  entering  into  the  form- 
ation of  the  joint;  for  example,  in  a  genuinely  stiff 
shoulder,  not  only  will  the  arm  be  incapable  of  full  up 
and  down  motion,  but  there  will  be  also  a  movement  of 
of  the  entire  shoulder-blade  when  attempts  are  made 
to  perform  any  of  the  usual  arm  motions,  because  the 
arm  is  firmly  glued  into  the  socket  of  the  shoulder- 
blade,  and  for  functional  purposes  there  is  no  separ- 
ation or  joint. 

INABILITY  TO  CONTRACT  the  muscles  is  also  a  neces- 
sary sequence,  because  there  is  so  much  loss  of  mus- 
cular tissue  and  tone  that  normal  action  of  the  mus- 
cles is  prevented  and  function  is  impaired. 

Of  course,  the  firmer  and  more  complete  the  stiffness, 

86 


the  greater  will  be  the  prominence  of  the  above  diag- 
nostic symptoms;  in  addition,  there  are  other  less  im- 
portant, but  corroborative 

ACCESSORY  DIAGNOSTIC  SIGNS: 

1.  TEXTURE  of  the  skin.  If  it  be  firm  and  hard 
or  calloused,  the  surmise  is  that  function  is  not 
abolished  to  the  claimed  extent. 

2.  SENSATION  to  pain  and  touch  is  usually  lessened 
to  some  degree,  especially  in  long  standing  and 
severe  cases. 

3.  ACTION  of  surrounding  joints  is  sometimes  dim- 
inished because  they  also  are  less  used ;  for  example 
in  a  stiff  shoulder,  the  elbow  would  be  less  em- 
ployed than  normally  and  perhaps  exhibit  some  of 
the  signs  of  the  involved  joint,  especially  as  many  of 
the  affected  muscles  have  an  action  on  both  joints. 

4.  TRANSPOSAL  of  function  so  that  the  opposite 
unimpaired  side  become  more  dexterous ;  this  is 
well  shown  where  a  right  side  is  injured,  the  left 
being  trained  to  take  its  place. 

5.  ATTITUDE  of  unconsciously  favoring  the  affect- 
ed part  in  every  movement;  to  a  trained  eye,  this 
is  one  of  the  most  certain  of  signs. 

COMMON   SITES  OF  JOINT  STIFFNESS. 

1.  SHOULDER:— This  may  be  total,  but  commonly 
is  claimed  to  affect  motion  beyond  a  right  ankle  so 
that  the  outstretched  arm  can  be  lifted  only  as  high 
as  the  shoulder.     Common  causes  of  this  are: 

(a)  Dislocation  of  shoulder: 

(b)  Fracture  of  upper  end  of  arm ; 

(c)  Fracture  of  Clavicle  (collar  bone)  ; 

(d)  Sprains  of  much  severity. 

If  the  disability  is  genuine,  the  most  apparent  signs  will 
be: 

(a)     ATROPHY    (wasting)    of   the    Deltoid    muscle 

87 


(that  which  caps  the  outside  of  top  of  shoulder) 
and  to  a  lesser  degree  of  Trapezius  muscle  (that 
on  back  of  neck  reaching  to  top  of  shoulder- 
blade). 

(b)  ATROPHY  of  Biceps  and  Triceps  muscle  (mid- 
dle of  arm). 

(c)  FIXATION  of  head  of  arm  bone  so  that  it  can- 
not be  rotated  without  moving  the  shoulder-blade. 

2.  KNEE: — Stiffness  here  may  be  total,  either  in  a 

straight  or  partly  bent  position,  but  commonly  the 
claim  is  that  the  part  cannot  be  bent  beyond  a 
right  angle. 
Common  causes  of  this  are: 

(a)  Fractures  about  the  joint,  as  of  the  Patella  (knee- 
cap) or  lower  end  of  Femur  (thigh)  or  upper  end 
of  Tibia  (shin)  ; 

(b)  Synovitis  of  knee  due  to  severe  Contusions  or 
Sprains. 

If  the  fixation  be  genuine,  there  will  be ; 

(a)  ATROPHY  of  the  muscles  above  and  be- 
low the  joint ; 

(b)  WRINKLING  or  swelling  of  the  joint  itself 
depending  upon  the  underlying  cause; 

(c)  DIMINISHED  or  abolished  motion  be- 
tween the  lower  end  of  the  Femur  (thigh) 
and  upper  end  of  Tibia  (shin)  ; 

(d)  APPEARANCE  of  the  shoes;  in  a  genuine 
stiffness,  there  will  be  a  limp  or  swinging 
of  the  foot  to  cause  wearing  of  the  sole  in  a 
manner  different  from  the  opposite. 

3.  HIP: — This  is  rarely  total,  but  most  frequent- 
ly the  claim  is  (as  in  the  foregoing)  of  the  inabil- 
ity to  bend  beyond  a  right  angle,  or  of  being  fixed 
in  some  vicious  position,  so  that  lateral  as  well  as 
up  and  down  motion  is  limited. 

Common  causes  are: 


88 


(a)  Sprains  or  very  severe  Contusions  accom- 
panied by  Synovitis; 

(b)  Fractures  of  Neck  of  Femur  (thigh  at  hip- 
socket). 

(c)  Dislocations. 

4.     ELBOW: — the  most  common  abnormal  position  is 
one  midway  between  a  right  angle  and  a  straight 
position  but  all  intermediate  degrees  are  met  with. 
Common  causes  are : 

(a)     Severe    Contusions    and    Sprains    in    which 
long    immobilizing    (splints    or    bandages) 
has  been  employed : 
(c)     Fractures;  as  of  the  upper  end  of  Ulna  (in- 
ner forearm  bone)   or  Radius   (outer  fore- 
arm bone)  or  lower  end  of  Humerus  (arm 
bone). 
The  HIP  and  ELBOW  give  corroborative  signs  similar  to 
those  mentioned  for  the  SHOULDER  and  KNEE.    Any  of  the 
other  joints  may  be  similarly  affected  by  a  like  set  of  causes, 
the  rule  being  that  stiffness  is  directly  proportionate  to  the 
severity  of  joint  damage  and  the  period  of  disuse. 

LIMITS  OF  NORMAL  JOINT  MOTION. 

There  are  very  few  joints  called  upon  to  perform  their  full 
limit  of  motion  in  order  that  an  individual  may  carry  on  his 
usual  occupation ;  only  an  acrobat  is  concerned  as  to  the  abil- 
ity to  bend  the  knees  far  enough  to  cause  the  heels  to  meet 
the  buttocks,  or  to  spread  the  hips  to  the  extent  of  "doing 
the  split."  This  gives  rise  to  the  phrase,  "FUNCTIONAL 
ACTIVITY  OF  A  JOINT",  this  implying  the  usual  and  or- 
dinary motion  performed  by  the  part  during  average  daily 
necessity.  Hence  it  is  that  the  measure  of  success  after  a 
joint  injury  is  dependent  upon  its  relation  to  the  "functional 
activity"  of  the  joint,  and  not  upon  the  "physiological  activity", 
the  latter  meaning  the  fullest  possible  range  of  motion  by  un- 
usual effort.  A  joint  functionally  recovers  following  an  in- 
jury when  all  practical  purposes  are  subserved,  despite  the 

89 


fact  that  extraordinary  actions  are  diminished  or  abolished. 

Surgeons  also  make  use  of  the  term  "THE  NORMAL  CAR- 
RYING ANGLE",  meaning  thereby  the  usual  position  as- 
sumed by  a  joint  when  unengaged  in  some  special  act. 

The  CARRYING  ANGLE  of  the  arm  at  the  elbow  is  not  a 
straight  line  (180  degrees),  but  there  is  a  slight  outward  bend 
of  the  elbow  (with  the  hand  dangling  at  the  side  with  inturned 
palm)  causing  the  extremity  to  assume  an  angle  of  160  degrees; 
hence  it  is  no  measure  of  elbow  recovery  to  assert  inability  to 
make  the  arm  and  forearm  assume  a  straight  axis. 

Similarly  the  KNEE  AND  WRIST  are  not  in  the  same  ab- 
solutely straight  axis  to  the  limb  to  which  they  are  attached. 

CAUSES  OTHER  THAN  INJURY  FOR  JOINT  STIFF- 
NESS. 

i.  RHEUMATISM  affecting  the  joint  itself  or  the 
muscles  adjacent. 

2.  NEURITIS  (inflammation  of  nerve  fibre)  due  to 
any  cause  other  than  injury,  such  as  ALCOHOL, 

LEAD,  ARSENIC  (or  other  poisons)  or  to  OC- 
CUPATIONS calling  for  constant  pressure  along 
nerve  trunks;  or  to  germ  diseases,  such  as  GRIPPE 
and  TYPHOID  FEVER. 

3.  DISEASE  of  germ  origin,  notably  GONOR- 
RHOEA in  the  form  of  GONORRHOEAL 
RHEUMATISM. 

4.  BRAIN  OR  SPINAL  CORD  disease,  of  which 
APOPLEXY  and  LOCOMOTOR  ATAXIA  are 
types. 

TREATMENT:     This    may   be    said    to   be    (a)    Prophylac- 
(preventative),  and  (b)  Curative: 

(a)  PROPHYLACTIC  treatment  aims  to  se- 
cure use  of  an  injured  joint  before  idleness 
causes  or  increases  stiffness ;  with  this  in 
view,  Splints  and  Bandages  are  early  re- 
moved, massage  and  gradual  use  institut- 
ed   and    stiffness   overcome.      (See    Treat- 

90 


ment    in    "Fractures",    "Dislocations",   and 

"Sprains  and  Contusions"), 
(b)     CURATIVE  treatment  aims  to  break  up 

the   fibrous  or   bony  bands    ("Adhesions") 

locking  the  joint,  and  this  is  done  by: 
i.     Massage    (by  hand,  or  vibratory   machine)  ; 

2.  Slight  movement  of  the  joint,  by  Doctor  or 
patient  or  attendant; 

3.  Forced  movement  of  the  joint,  by  Doctor  or 
patient  or  attendant ; 

4.  Electricity; 

5.  Chloroform,  or   Ether,  or  "Laughing   Gas" ; 

6.  Operation. 

When  the  joints  are  firmly  bound,  the  administration  of 
small  amounts  of  Chloroform,  or  Ether,  or  "Laughing  Gas" 
(Nitrous  Oxide)  will  relax  contracted  muscles  and  permit 
painless  forced  motion ;  under  such  circumstances,  the  "fibrous 
adhesion"  can  be  frequently  heard  to  snap  when  "broken  up." 

If  the  above  method  fails,  incision  into  the  joint  is  needed, 
the  adherent  surfaces  are  partly  severed,  but  full  restoration 
does  not  usually  occur  if  the  relaxation  be  firm  enough  to  re- 
quire this  procedure  which  is  usually  demanded  only  in  bony 
ankylosis. 

Certain  Surgeons  and  Hospitals  employ  an  apparatus  (tech- 
nically known  as  an  Arthromotor)  to  mechanically  move  stiff 
joints,  and  many  remarkable  results  are  thereby  obtained  in 
apparently  hopeless  cases. 


91 


XVIII.     HERNIAE. 


A  HERNIA,  commonly  called  rupture,  is  the  protrusion  of 
any  organ,  or  portion  of  an  organ,  from  its  normal  position 
within  the  body. 

As  ordinarily  applied,  the  term  means  the  presence  of  a 
rupture  in  the  groin,  this  remaining  therein  or  pushing  its 
way  further  down  to  show  in  the  scrotum  (bag  enclosing 
testicles). 

ANATOMY:  That  part  of  the  body  in  which  Herniae  (Rup- 
tures) most  often  appear  is  the  lower  segment  of  the  abdomen 
in  the  region  of  the  groin,  this  latter  being  technically  known 
as  the  INGUINAL  REGION,  and  it  corresponds  to  the  crease 
at  the  junction  of  the  front  of  thighs  and  the  abdomen. 

This  part  of  the  body  is  layered  by  many  muscles  which  are 
superimposed  in  a  shingle-on-a-roof  manner,  and  normally 
there  are  no  intervening  spaces  through  which  the  abdominal 
organs  might  escape  under  the  influence  of  sudden  or  prolonged 
pressure.  However,  in  the  lower  inner  part  of  this  crease,  there 
is  a  grove  or  canal  which  is  called  the  INGUINAL  CANAL, 
and  through  it  passes  (in  men)  a  cord  that  goes  down  to  the 
testicle  on  each  side ;  in  women  this  is  called  the  Round  Lig- 
ament and  it  is  one  of  the  guy-ropes  of  the  womb.  This  CAN- 
AL is  about  two  inches  long,  (and  runs  outward  from  the  mid- 
dle of  the  lower  abdomen)  and  at  each  end  of  it  is  a  RING  or 
constriction ;  the  one  furthest  in  is  called  the  INTERNAL  AB- 
DOMINAL RING,  or  INTERNAL  RING,  and  the  one  near- 
est the  skin  is  called  the  EXTERNAL  ABDOMINAL  RING 
or  EXTERNAL  RING.     (See  Diagram.) 

At  birth,  the  testicles  escape  through  these  RINGS  along 
the  CANAL,  and  Nature  then  shuts  in  the  CA^AL  to  pre- 
vent any  of  the  intestines  or  abdominal  contents  from  getting 
through  also;  but  in  some  instances,  Nature  does  not  do  her 
work  thoroughly,  or  the  individual  is  perversely  constructed, 

92 


and  a  piece  of  intestine  or  its  covering  will  manage  to  protrude 
— and  then  we  have  what  is  called  a  CONGENITAL 
HERNIA. 


The   anatomy   of   inguinal   and   femoral   hernia    (Leidy).     8,    Inguinal 
Canal;  n,  External  Ring;  17,  Location  of  Femoral  Hernia. 

All  Herniae,  according  to  their  location,  can  be  roughly  div- 
ided into  four  kinds : — 

1.  INGUINAL  HERNIA— that  which  shows 
itself  as  a  rupture  of  the  groin; 

2.  FEMORAL  HERNIA— that  which  shows 
itself  as  a  rupture  in  the  upper,  inner  thigh, 
below  the  creases  of  the  groin ; 

3.  UMBILICAL  HERNIA  —  that  which 
shows  itself  as  a  rupture  through  the 
navel ; 

4.  VENTRAL  HERNIA— that  which  shows 
itself  as  a  rupture  through  any  part  of  the 
the  abdominal  wall  other  than  the  navel. 

INGUINAL  HERNIA:    This  is  the  commonest  form  of  rup- 
ture, and  can  be  divided  into  two  sorts : — 

(a)  Direct  (also  called  Internal). 

(b)  Indirect  (also  called  Oblique  or  External). 

93 


DIRECT  INGUINAL  HERNIA  is  the  rarer 
of  the  two  forms,  and  by  it  is  meant  a  push- 
ing out  of  a  piece  of  the  intestine  or  intest- 
inal covering  (omentum),  this  showing, 
as  an  enlargement,  about  the  middle  of  the 
groin ;  this  form  does  not  follow  the  course 
of  the  "Canal." 
INDIRECT  INGUINAL  HERNIA  is  the 
commonest  form  met  with,  and  forms  93% 
of  all  inguinal  herniae.  This  is  a  protru- 
sion through  the  natural  openings  in  the 
abdominal  wall,  the  enlargement  travers- 
ing the  fold  of  the  groin  and  showing  itself 
as  an  enlargement  within  or  close  to  the 
scrotum;  if  it  remains  in  the  Canal  it  is 
known  as  a  BUBONOCELE;  if  it  reaches 
the  scrotum  it  is  then  referred  to  as  a 
SCROTAL  HERNIA,  and  this  last  named 
form  is  almost  always  of  congenital  origin. 
HERNIAE  are  further  subdivided  by  their  capability  of  be- 
ing pushed  back  into  their  normal  position ;  that  is,  they  are 
either: 

(a)  Reducible ; 

(b)  Irreducible; 

(c)  Strangulated. 

REDUCIBLE  HERNIAE:  A  reducible  hernia  is  one  that 
can  be  readily  replaced  and  made  to  disappear,  this  us- 
ually occurring  when  the  individual  lies  down  or  when 
the  enlargement  is  manipulated,  and  it  then  disappears 
with  a  characteristic  gurgling  sound — hence  the  ne- 
cessity of  examining  the  patient  while  standing. 

IRREDUCIBLE  HERNIAE:  An  irreducible  hernia  is  one 
that  cannot  be  pushed  back  into  its  normal  position, 
even  under  the  influence  of  an  anaesthetic.  A  further 
degree  of  this  form  of  hernia  is  sometimes  referred  to 
as  an  INCARCERATED  HERNIA. 

94 


STRANGULATED  HERNIAE:  A  strangulated  hernia  is 
that  form  where  the  intestine  or  its  covering  has  been 
literally  strangled  so  that  its  circulation  is  shut  off  and 
the  part  is  practically  dead.  This  is  the  dangerous 
element  of  any  hernia,  and  is  liable  to  occur  if  the  in- 
dividual over-exerts  himself,  or  if  an  improperly  fitting 
truss  be  worn ;  such  a  contingency  demands  an  im- 
mediate operation,  and  even  then  recovery  is  often- 
times problematical. 

CAUSES:  One  in  every  20  to  30  persons  has  a  Rupture  of 
some  sort. 

It  is  3  times  more  frequent  in  men  than  women,  and 
occurs  oftener  on  the  right  side. 

All  Herniae  are  either  Natural  or  Acquired. 

A  NATURAL  HERNIA  may  be  congenital,  due  to 
some  defect  in  the  abdominal  wall  by  which  the  nor- 
mal openings  have  never  been  properly  closed  or  pro- 
tected ;  it  may  also  follow  a  decrease  in  bodily  tissue  so 
that  a  fat  person  becomes  thin,  this  increasing  the  size 
of  the  openings  which  normally  existed.  Conversely,  it 
occasionally  occurs  in  people  who  have  suddenly  be- 
come fat ;  this  causing  a  stretching  and  widening  of 
normal  openings. 

ACQUIRED  HERNIAE  are  the  result  of  long  con- 
tinued INTRA-ABDOMINAL  strain  or  pressure,  and 
they  almost  never  occur  as  a  result  of  a  single  sudden 
act  of  violence.  Any  occupation  that  calls  for  strain  or 
stress  upon  the  abdominal  muscles,  or  in  which  lifting 
is  demanded,  or  where  vomiting  or  coughing  ensue,  or 
where  the  parts  have  been  weakened  by  operations  or 
the  wearing  of  apparatus,  or  following  pregnancy; 
then,  under  such  circumstances,  herniae  are  liable  to 
occur.  Individuals  developing  a  hernia  under  condi- 
tions of  this  sort  (in  the  absence  of  some  unusual 
circumstances)  are  said  to  have  what  is  termed  a 
"HERNIAL  TENDENCY." 

95 


The  vast  majority  of  herniae  occur  very  gradually, 
and  most  authorities  doubt  the  possibility  of  a  com- 
plete hernia  occurring  INSTANTLY.  It  is  said  that 
only  between  6  and  7%  of  herniae  occur  within  a  short 
time  after  the  receipt  of  violence  (Von  Bergman's 
Surgery). 

In  an  Article  by  a  well  known  surgeon  of  New 
York   City,  the  statistics  of  50,000  cases, 
treated  at  the  New  York  Hospital  for  Rup- 
tured   and    Crippled,    show    only    FOUR 
CASES  in  which  the  rupture  was  directly 
attributable  to  an  injury. 
This  proportion  is  not  excessive,  and  it  is  in 
line  with  the  opinion  of  the  best  teachers, 
writers  and  practitioners. 
For  the  production  of  a  TRAUMATIC  HERNIA 
(one  due  to  an  injury),  there  are  two  essentials: 

1.  The  hernia  must  be  completely  developed 
IMMEDIATELY  after  or  within  a  very 
few  days  of  the  receipt  of  the  injury ; 

2.  There  must  have  been  no  predisposition  to 
hernia,  no  matter  of  what  nature. 

Nearly  all  the  authentic  cases  of  TRAUMATIC 
HERNIAE  that  have  been  reported  are  those  resulting 
from  a  sudden  impinging  of  the  affected  portion  of  the 
body  on  a  blunt  surface  and  the  immediate  occurence  in 
this  area  of  the  characteristic  swelling,  usually  accom- 
panied by  more  or  less  discoloration.  The  majority  of 
of  these  cases  have  been  the  result  of  kicks  directly 
over  the  part  of  the  body  where  the  rupture  showed 
itself,  or  falls  from  a  height  so  that  the  individual  im- 
pacted upon  some  sharp  raised  surface. 

Indirect  violence,  such  as  a  fall  upon  the  feet  or 
back  or  buttooks,  cannot  be  looked  upon  as  a  causative 
factor,  because  of  the  fact  that  the  transmitted  concus- 
sion has  so  many  obstacles  before  it  reaches  the  usual 

96 


location  for  the  occurrence  of  a  rupture ;  so  that  what 
is  known  as  "CONCUSSIVE  FORCE"  is  not  looked 
upon  as  a  productive  feature. 

It  cannot  be  denied,  however,  that  any  accident 
which  increases  the  pressure  within  the  abdomen  in  a 
person  with  a  hernial  tendency  may  be  a  producing 
cause  for  accelerating  or  producing  a  Hernia  that  was 
in  great  part  already  formed. 

SYMPTOMS:  The  vast  majority  of  persons  know  nothing 
of  the  existence  of  a  hernia  until  their  attention  is  called 
to  it  by  an  examination  for  some  other  purpose.  In- 
stances of  this  are  common  in  Life  Insurance,  Army 
and  Navy,  and  in  Civil  Service  Examinations. 

Certain  individuals  complain  of  a  dragging,  gnawing 
sensation  in  the  groin  or  in  the  region  of  the  testicles, 
and  occasionally,  by  self-examination,  feel  a  protrusion. 
It  is  notoriously  true  that  a  well  developed  hernia  may 
exist  for  a  long  time  without  giving  any  symptoms 
whatever.  If  the  hernia  becomes  strangulated  the  in- 
dividual becomes  extremely  ill,  has  a  distended  abdo- 
men, vomits,  and,  in  a  word,  has  the  usual  signs  of 
Peritonitis. 

When  a  Hernia  is  claimed  to  have  occurred  as  the  direct  re- 
sult of  an  accident,  the  following  factors  must  be  complied 
with : 

i.  There  must  have  been  no  "Hernial  Tendency;"  by  this  is 
meant  that  the  individual  must  not  have  had  struct- 
urally weak  abdominal  muscles,  and  the  "Rings"  must 
not  have  been  abnormally  large  (ordinarily  each  "Ring" 
will  admit  the  tip  of  the  little  finger). 
2.  The  violence  must  be  inflicted  in  the  region  where  the 
Hernia  subsequently  appears ;  it  is  anatomically  im- 
possible for  a  blow  at  a  distance  from  the  groin  to  be 
forcibly  enough  transmitted  to  cause  a  Hernia  in  that 
location. 

97 


3.  There  must  be  almost  immediate  protrusion  in  the  injured 

site  of  the  Intestine  or  its  covering;  and  the  smaller 
the  protrusion,  the  greater  likelihood  of  recent  origin. 
It  is  practically  impossible  for  a  "lump"  larger  than  a 
walnut  to  appear  as  a  result  of  the  ordinary  single  act  of 
violence,  and  if  the  Hernia  remains  in  the  "Canal,"  the 
diagnosis  of  recency  is  also  fortified. 

4.  There  are  usually  signs  of  Shock  (faintness,  pallor,  nausea, 

weak  pulse,  etc.,)  following  a  blow  on  the  abdomen 
severe  enough  to  force  out  abdominal  contents  through 
well  protected  walls. 

5.  There  are  usually  signs  of  discoloration  (Contusion)  in  the 

vicinity  of  the  recently  formed  Rupture,  and  not  infre- 
quently, a  local   inflammation  also. 

6.  There  must  be  no  laxness  of  the  abdominal  wall,  or  of  the 

Scrotum  (bag  holding  testicles),  nor  dimpling  of  the 
skin  in  the  region  of  the  Hernia. 

7.  There  must  be  absence  of  the  characteristic  glossy,  smooth 

appearance  of  the  skin  near  the  Hernia,  these  all  being 
denotive  of  long  continued  prior  tension  of  a  pre-formed 
"Lump"  ;  harshness  of  the  skin,  and  some  tanning  of  it, 
usually  indicates  the  pressure  of  a  Truss. 

8.  The  person  recently  herniated  acts  in  a  characteristically 

careful  manner  and  unconsciously  favors  a  part  which 
he  knows  to  have  been  recently  damaged ;  absence  of 
this  affords  strong  corroboration  of  a  suspected  ancient 
Rupture. 

9.  Rupture  on  each  side  of  the  abdomen  usually  verifies  old 

origin  and  decided  "Hernial  Tendency." 

TREATMENT:.  This  can  be  either: 

(a)  Palliative;  or 

(b)  Radical. 


By  PALLIATIVE  TREATMENT  is  meant  the 
wearing  of  a  truss  or  other  apparatus  to  keep  the  en- 
largement in  place;  and  in  children  the  use  of  such  an 
apparatus  will  sometimes  cause  the  enlargement  to  dis- 
appear, but  in  adults  spontaneous  cure  is  practically  un- 
known. 

RADICAL  TREATMENT:  This  implies  a  cutting 
operation  in  which  the  protrusion  is  exposed,  then  re- 
turned to  its  former  location,  and  the  Ring  is  sewed  up 
and  narrowed ;  the  patient  is  usually  two  or  three  weeks 
in  bed,  and  at  the  end  of  six  weeks  or  two  months  re- 
turns to  his  regular  duties,  and  in  six  months  is  practi- 
cally as  well  as  ever.  The  mortality  following  such  an 
operation  is  very  small  and  it  is  one  of  the  safest  and 
surest  of  modern  surgery.  This  operation  is  frequently 
done  under  cocaine,  and  less  than  one-half  of  a  grain 
of  the  drug  is  needed.  The  operation  (either  under  a 
general  or  local  anaesthetic)  takes  from  15  to  35 
minutes,  and  little  or  no  pain  is  felt  while  in  bed. 


99 


XIX.     UTERINE     TROUBLE 


The  Female  Generative  Organs  consist  of  the  WOMB  or 
UTERUS,  and  on  each  side  of  this  is  an  OVARY  connected  to 
the  \Y<  >M  II  by  the  FALLOPIAN  TUBE.     (See  Diagram.) 


Front  view  of  the  internal  generative  organs  (Leidy.)  i,  Womb;  3, 
Cervix  or  Neck  of  Womb;  7,  Broad  Ligament;  9,  Fallopian  Tubes; 
11,  Ovary. 

The  above  organs  rest  in  what  is  technically  known  as  the 
PELVIS ;  that  is,  the  lower  half  of  the  bones  which  form  the 
flanges  of  the  hips. 

ANATOMY: 

THE  UTERUS  is  a  pear-shaped  organ,  varying  in  size  from 
three  to  four  inches  in  length  and  from  one  and  one- 
half  to  two  and  one-half  inches  in  breadth. 

It  is  suspended  in  the  lower  part  of  the  pelvis  with 
the  heavy  end  upward  and  forward,  seated  at  an  angle 
of  about  65  degrees,  vertically. 

The  upper  part  of  it  is  called  the  FUNDUS  (roof)  ; 
the  middle  part  is  the  BODY;  and  the  lower  part  the 
CERVIX  (neck). 

It  is  normally  held  in  position  by  a  series  of  eight 
elastic  guy-ropes  termed  LIGAMENTS  which  hold  it 
suspended  and  allow  the  greatest  motility,  so  that  it 
can  be  moved  a  distance  of  several  inches  in  all  direc- 
tions; hence,  under  the  influence  of  an  anaesthetic 
it  can  be  pulled  down  so  that  its  neck  can  be  shown  at 
the  outlet  of  the  vagina  ("Privates"). 

100 


These  eight  Ligaments  are: — 

The  ANTERIOR,  reaching  from  front  of  Uter- 
us to  the  Bladder. 
The    POSTERIOR,    reaching    from    back    of 
Uterus  to  the  spinal  column  (Sacrum)  and 
Rectum. 
TWO  LATERAL,  or  BROAD  LIGAMENTS, 
reaching  from  each  side  of  Uterus  to  the 
bony  flange  of  hips  (the  Pelvis)  ;  these  en- 
close the  Ovaries  and  the  Fallopian  Tubes, 
the  latter  joining  each  Ovary  to  the  Uterus. 
These  are  the  main  supports  and  are  very 
strong  and  important. 
TWO  SACRO-UTERINE,  reaching  from  the 
lower  end  of  Sacrum  (near  the  lower  part 
of  spinal  column)  to  the  neck  of  the  Uter- 
us ;  that  is,  nearly  to  the  lower  front  of  the 
organ. 
TWO    ROUND    LIGAMENTS,    reaching    a 
distance  of  four  or  five  inches  from  the  up- 
per part  of  Uterus  and  running  in  the  above 
Broad  Ligaments  to  the  front  of  abdomen, 
then  through  a  hole  in  the  muscles  there 
(Internal  Abdominal  Ring)  and  finally  end- 
ing in  the  outside  lips  of  the  Vagina. 
Hence  it  can  be  seen  that  the  Uterus  is  steadied  in  a  remark- 
able manner  by  three  ligaments  going  from  the  front, 
three  from  the  back,  and  two  from  the  sides. 
It  is  further  protected  by  a  wise  Nature  in  being  situated  deep 
in  the  abdomen,  with  the  soft  and  always  more  or  less 
filled  bladder  in  front,  and  an  almost  equally  elastic 
rectum  back  of  it,  each  acting  as  a  water-bumper.    On 
top,  it  is  surrounded  by  a  similar  cushion  of  intestines ; 
and  on  each  side  it  has,  in  addition,  the  bony  barrier  of 
the  flanges  of  the  hips  ("Pelvic  Bones"),  and  outside 
of  this  the  thick  muscles  of  the  buttocks. 


101 


There  is  no  organ  in  the  body  better  isolated,  and  none  more 
invulnerable  to  outside  violence  or  structurally  better 
protected  to  perform  the  important  function  of  repro- 
duction. 
MAL-POSITIONS  OF  THE  UTERUS: 

It  may  be  displaced  downward,  technically  known  as 
PROLAPSED;  forward,  technically  known  as  AXTE- 
VERTED  or  ANTEFLEXED;  or  backward,  technic- 
ally known  as  RETROVERTED  or  RETRO- 
FLEXED. 

"FLEXION"  as  a  suffix  means  a  displacement  great- 
er in  degree  than  "VERSION." 
DOWNWARD  DISPLACEMENTS  OF  THE  UTERUS— 
or,  technically,  "PROLAPSUS  UTERII"— is  one  of 
the  rarer  displacements  of  the  WOMB,  and  almost  in- 
variably occurs  in  those  who  have  had  children.  This 
is  due  to  the  fact  that  a  main  support  of  the  uterus 
(preventing  its  sagging  into  the  pelvic  cavity)  is  a 
strong  band  of  muscle  and  fibre  which  guards  and 
floors  the  space  between  the  vagina  and  rectum.  This 
space  is  technically  known  as  the  PERINEUM.  In 
childbirth,  especially  at  the  initial  confinement,  this 
perineum  is  almost  always  torn ;  and — unless  it  is  care- 
fully sewed — it  offers  a  natural  means  for  downward, 
forward,  or  backward  displacements. 

Other  causes  of  this  "FALLING  OF  THE  WOMB" 
would  be  anything  causing  pressure  on  the  interior  of 
the  abdomen  so  as  to  force  the  womb  from  its  normal 
position ;  such  as  tumors  within  the  abdomen,  dropsy, 
and  (occasionally)  tight  lacing,  or  a  very  protuberent 
or  fat  abdomen. 
DEGREES  OF  PROLAPSED  UTERI: 

FIRST   DEGREE,   that  in  which   the   womb  is  but 

slightly  displaced; 
SECOND   DEGREE,   where   it   can   be   seen   at   the 

outlet  of  the  vagina ; 

102 


THIRD  DEGREE,  where  it  comes  between  the  lips 
of  the  vagina  and  rests  within  the  thighs. 

INJURY  CAN  NEVER  directly  produce  this  condition  ex- 
cept the  violence  be  inflicted  upon  the  abdomen  so  as 
to  force  the  womb  and  other  contents  downward — as 
by  the  passage  of  a  wheel  over  a  prostrate  body. 

ANTEVERSION  and  ANTEFLEXION :  The  womb  is  nor- 
mally anteverted,  that  is,  turned  forward;  but  if  this 
turning  forward  exceeds  an  angle  of  65  degrees,  the 
condition  passes  into  one  of  ANTEFLEXION ;  that 
is,  a  definite  bending  forward. 

This  is  rather  a  rare  condition,  and  occurs  usually 
in  those  who  have  had  inflammation  of  the  vagina  or 
ovaries  or  tubes;  however,  tight  lacing;  straining,  as 
in  relieving  the  rectum  or  bladder ;  long  continued 
standing;  sneezing;  violent  coughing;  or  any  unusual 
muscular  effort,  as  in  lifting  a  heavy  object  from  the 
floor — all  may  also  cause  this  anteflexion. 

A  fall  from  a  height  with  the  violence  transmitted 
to  the  pelvis,  either  by  landing  on  the  feet  or  buttocks, 
can  also  contribute  to  its  causation  in  those  predisposed. 
Many  Surgeons  claim  that  it  is  impossible  to  cause 
forward  displacements  and  that  all  such  cases  are  con- 
genital. 

RETROVERSION  and  RETROFLEXION:.  This  is  the 
commonest  form  of  uterine  displacement,  and  is  usually 
associated  with  more  or  less  downward  displacement 
of  the  womb  (PROLAPSE). 

It  can  occur  from  any  of  the  causes  given  above  for 
forward  displacements,  but  is  most  commonly  found  in 
those  who  have  borne  children  and  hence  have  a  pre- 
disposition. 

In  discussing  the  displaced  conditions  of  the  uterus,  it  must 
be  remembered  that  any  displacement  may  be  congenital  as 
well  as  acquired. 


103 


DISPLACEMENTS  forward  and  backward  have  a  definite 
set  of  symptoms;  and  they  may  be  summed  up  as  follows: 

Pain  in  the  back  ; 

"Bearing  down  sensation" ; 

Headache  at  the  nape  of  the  neck ; 

Constipation  and  irritability  of  the  bladder,  so 
that  the  individual   has  difficulty  in   long 
retaining  the  urine. 
With  the  above  are  also  associated: 

Catarrhal  discharge  from  the  vagina  (known  as 
LEUCORRHEA;  or,  colloquially,  "THE 
WHITES")  ; 

More  or  less  disturbance  and  pain  in  men- 
struation ; 

And  almost  always  that  set  of  neurotic  symp- 
toms termed  by  the  laity  "nervousness." 

Granting  a  healthy  woman  with  normal  muscular  and  lig- 
amentous supports,  it  requires  considerable  violence 
to  displace  so  small  and  well  protected  an  organ,  es- 
pecially when  it  is  considered  that  it  has  a  normal  range 
of  motion  of  several  inches,  to  which  it  is  daily  sub- 
jected in  the  jostle  and  strain  of  activity. 

But  in  a  woman  who  has  borne  children,  and  in 
whom  the  ligaments  have  thereby  become  stretched 
and  inelastic,  and  in  whom  the  normal  muscular  floor- 
ing has  become  torn  from  the  same  cause,  the  condi- 
tions are  vastly  different,  and  violence  might  play  an 
ulterior  role.  However,  it  must  be  remembered  that  a 
single  act  of  violence,  even  in  a  person  thus  predisposed, 
is  not  nearly  so  potent  a  causative  factor  of  displace- 
ment as  is  constant,  long  continued  lack  of  support  and 
undiminished  pressure;  and  the  vast  majority  of  dis- 
tortions found  in  those  who  have  borne  children 
long  antedated  the  ordinary  accident  alleged  to  have 
been  the  only  producing  cause.     Proof  positive  as  to 

104 


£his  is  afforded  if  the  organ  is  bound  down  and  im- 
movable, the  technical  descriptive  term  being  "Ad- 
hesions" or  "Adherent";  this  always  indicates  chron- 
icity  and  inflammation  not  attributable  to  trauma. 
Practically  there  are  only  three  common  causes  for  displace- 
ments : 

Congenital  origin;  pregnancy;  germ  inflammation  (as 
Gonorrhoea,  Abortions,  or  pus  collections). 
DURATION:  Any  displacement  of  the  womb  that  is  due 
to  injury  occurs  at  once  so  soon  as  the  violence  is  in- 
flicted, and  is  usually  associated  with  definite  symp- 
toms of  shock,  so  that  the  individual  is  aware  that 
something  unusual  has  happened. 

If  treatment  is  at  once  resorted  to,  the  mal-position 
can  be  corrected  and  will  not  tend  to  become  worse ; 
and,  in  a  general  way,  it  can  be  said  that  nearly  all  dis- 
placed conditions  of  this  organ  are  capable  of  almost 
complete  relief. 

Many  women  have  a  marked  displacement  and  at- 
tribute its  symptoms  to  other  causes,  notably  to  lum- 
bago or  rheumatism ;  in  many,  symptoms  are  entirely 
lacking  even  in  decided  malposition. 
TREATMENT:    This  may  be: 
i.     Palliative. 
2.     Radical. 

By  the  PALLIATIVE  treatment  is  meant  the  bet- 
tering of  the  individual's  general  condition  by  the  use 
of  tonic's,  and  relief  of  the  catarrh  by  douches;  and 
in  correcting  the  distorted  position  by  the  wearing  of 
some  form  of  apparatus  to  hold  the  displaced  organ  in 
its  position. 

Apparatus  designed  for  this  purpose  is  technicallv 
known  as  a  PESSARY,  and  is  usually  a  hard  or  soft 
rubber  disc  which  is  placed  either  in  front  or  behind 
the  womb  within  the  vagina,  and  is  worn  with  com- 
parative comfort. 

105 


Cotton,  rolled  into  balls — technically  known  as 
TAMFOXS — also  serves  the  same  purpose. 

The  RADICAL  cure  of  a  displaced  uterus  is  by 
means  of  an  operation ;  and  this  designs  to  shorten  the 
ligaments  which  are  stretched,  and  repair  the  floor  of 
the  pelvis  (the  PERIXEUM)  so  as  to  make  the  organ 
resume  its  usual  position  by  restoring  its  normal  elas- 
tic supports. 


106 


XX.  MOVABLE  AND  FLOATING  KIDNEYS. 


By  "Movable  Kidney"  is  meant  any  descent  of  the  organ  be- 
yond a  few  inches  from  the  normal ;  a  "Floating  Kidney'* 
means  the  descent  below  the  foregoing  limit  and  the  ability 
to  move  the  organ  almost  at  will,  hence  this  variety  is  often 
called  "Wandering  Kidney." 

ANATOMY:    Each  kidney  is  about  four  inches   long,   two 

inches  wide,  and  one  inch  thick,  and  of  the  well-known 

semi-circular,  bean  shaped  appearance.    The  weight  is 

four  to  six  ounces. 

They  are  LOCATED  in  the  back  part  of  the  abdomen  and 

rest  in  the  hollows  of  the  arches  of  the  back  ("The  loins") 

very  close  to  the  spinal  column. 

They  are  COVERED  by  a  tough  fibrous  envelope  called 
the  CAPSULE,  and  this  in  turn  is  imbedded  in  a  mass  of 
fat,  the  latter  being  practically  a  guy  rope  maintaining  the 
normal  relations  of  the  organ ;  hence  when  the  fat  is  small  in 
amount,  motility  of  the  Kidney  is  permitted,  and  thus  it  is 
that  thin  persons  are  apt  to  have  displaced  Kidneys  (see 
below). 

Their  POSITION  can  be  determined  by  locating  the  last 
(12th)  Rib,  which  is  practically  at  the  middle  of  each  organ; 
a  line  drawn  around  the  body  at  the  level  of  the  navel  would 
be  a  little  below  the  lower  end  of  each  Kidney. 

The  Right  Kidney  is  about  one  inch  lower  than  the  left 
owing  to  the  fact  that  the  overlying  Liver  depresses  it  to  this 
extent;  hence  displacement  of  the  organ  is  more  usual  on  this 
side. 

There  is  a  NORMAL  MOVEMENT  of  each  Kidney  during 
the  usual  up  and  down  motion  of  chest  and  abdomen  in  respira- 
tion ;  so  that  the  determination  of  the  extent  of  motion  is  ar- 
bitrary, and  what  is  normal  for  one  is  abnormal  for  another. 

CAUSES  OF  DISPLACEMENT: 

(i)     CONGENITAL  mobility  is  not  rare    and    can 

107 


often  be  assumed  if  the  person  conform  to  the 
below  mentioned  "Movable  Kidney  Type." 
(2)     ACQUIRED  mobility  is  the  result  of  any  con- 
dition robbing  the  kidney  of  its  normal  sup- 
ports, such  as: 

(a)  Prolonged  muscular  effort  or  strain,  as  in 

lifting. 

(b)  Any  constriction  about  or  above  kidney- 

level,  as  tight  lacing. 

(c)  Any  pressure  from  above,  as  by  enlarge- 

ment of  the  liver,  stomach  or  other 
organs. 

(d)  A  general  lowering  or  drooping  of  all  the 

organs  of  a  relaxed  abdomen  due  to 
former  obesity  or  other  causes ;  this  is 
called  ENTEROPTOSIS,  as  the  intes- 
tines occupy  an  especially  low  position. 

(e)  TRAUMA   applied   to  the  back,  in    the 

neighborhood  of  the  kidney,  so  as  to 
jar  it  from  position;  or  severe  falls 
upon  the  feet  or  buttocks,  the  trans- 
mitted impact  stretching  or  loosening 
the  supports. 

(f)  Childbearing  causing  a    laxness    of    the 

supports  from  pressure. 

(g)  Tumors  or  other  enlargements  of  the  ab- 

domen, 
(h)     Prolonged  coughing,  gagging  or  vomit- 
ing, 
(i)      Certain  occupations  calling  for  bending  or 
arching  or  straining  of  back  or  abdo- 
men. 
FREQUENCY:     Fifteen  times  more   frequent  on   the   right 
than  left  side. 

Eighty-five  per  cent,  of  cases  in  women. 
Abnormally  low  in  from  twenty  to  forty-six  per  cent, 
of  all  women. 

108 


Movable  in  nearly  ninety-four  per  cent,  of  all  women, 
and  six  per  cent,  of  men  (quotation  from  Von  Berg- 
man's Surgery). 

Very  often  associated  with  Appendicitis. 

Can  "float"  far  enough  down  in  abdomen  to  impinge 
on  floor  of  pelvis  (bottom  of  abdomen),  and  give  no 
symptoms;  or  it  can  move  but  slightly,  and  yet  cause 
much  complaint. 

Von  Bergman's  Surgery  (written  by  a  famous  Ger- 
man surgeon)  and  edited  in  the  United  States  by 
Prof.  W.  T.  Bull  (of  New  York  City)  is  one  of  the 
latest  surgical  authorities,  and  it  states :  "At  any  rate 
most  who  complain  of  symptoms  due  to  movable  kid- 
ney are  of  the  nervous  type,  and  describe  pains  which 
are  partly  of  a  neuralgic  and  partly  of  a  hysterical 
character.  It  is  often  difficult  to  say  whether  the 
movable  kidney  is  the  cause  of  the  suffering  or  simply 
happens  to  be  present  in  some  individual  and  is  ob- 
served by  a  person  who  is  in  a  state  of  nervous 
excitability.  Be  that  as  it  may,  the  distress  may  be  so 
marked  as  to  be  unbearable  whenever  any  occupation 
is  undertaken.     .     .     ." 

SYMPTOMS:  Usually  those  of  Dyspepsia,  or  tenderness  in 
region  of  liver  or  large  intestine  or  region  of  ovaries  or 
appendix;  hence  the  symptoms  are  VERY  VARI- 
ABLE. 

Occasionally  pain  in  back  is  complained  of,  espe- 
cially on  exertion.  If  the  organ  "float,"  sometimes  the 
tube  leading  from  it  to  the  bladder  (the  Ureter)  be- 
comes twisted  and  the  urine  cannot  escape,  and  thus 
a  painful  engorgement  occurs  which  gives  symptoms 
allied  to  those  of  RENAL  COLIC  (pain  in  kidney  of 
the  type  found  when  a  stone  is  passed). 

There  are  a  host  of  HYSTERICAL,  or  NEURAS- 
THENIC, or  HYPOCHONDRIACAL  symptoms  al- 

109 


leged,  of   the   well-known   subjective   type,   especially 
by  women. 

DIAGNOSIS:  This  is  made  by  placing  the  patient  on  the 
back  with  knees  drawn  up,  and  locating  the  kidney  be- 
tween the  examiner's  hands,  one  of  which  is  placed 
on  abdomen,  and  the  other  on  the  patient's  back;  a 
deep  breath  is  then  taken,  the  kidney  comes  down  and 
the  distance  is  measured.  This  is  only  accurately  pos- 
sible in  a  reasonably  thin  person ;  a  very  obese  abdo- 
men makes  such  a  test  farcial,  and  further,  fat  people 
practically  never  have  displaced  kidneys. 

It  can  be  mathematically  demonstrated  whether  or 
not  a  given  person,  from  the  build,  is  entitled  to  a  dis- 
placed kidney ;  thus :  Take  the  distance  between  top 
of  breast-bone  (Suprasternal  notch)  and  the  middle 
of  the  bones  forming  the  floor  of  abdomen  (Symphysis 
Pubis)  and  divide  this  by  the  smallest  circumference 
of  the  abdomen,  and  multiply  the  result  by  ioo  (to 
eliminate  fractions)  and  the  result  will  be  from  63  to 
95,  the  mean  being  76.  Anything  above  76  means  a 
movable  kidney,  anything  below  shows  a  non-movable 
kidney.  This  gives  an  absolute  anatomical  and  mathe- 
matical basis  for  an  opinion,  and  surgeons  can  tell  at 
a  glance  if  the  person  is  of  the  "Movable  Kidney 
Type."     (Von  Bergman's  Surgery.) 

A  kidney  that  can  be  felt  is  not  necessarily  a  mov- 
able kidney  because  the  natural  descent  in  full  in- 
spiration (in  some  people)  allows  the  lower  edge  to 
come  in  contact  with  the  examiner's  hands. 

In  a  fit  subject,  squeezing  the  kidney  between  the 
examining  hands  causes  a  peculiar  nausea;  this  elim- 
inates the  possibility  of  mistaking  a  growth  or  other 
organ  for  the  kidney,  and  is  a  confirmative  test. 

In  some  persons,  examination  lying  on  the  back  is 
unavailing,  but  when  standing  slightly  bent  forward 

110 


with  the  hands  on  the  back  of  a  chair,  the  organ  can 
sometimes  be  better  mapped  out. 

Some  authorities  contend  that  a  Floating  Kidney 
is  always  congenital. 

TREATMENT:    This  is  (a)  Palliative  or  (b)  Radical. 

(a)  Palliative  Treatment  adopts  a  belt  or  specially 

shaped  corset  to  hold  the  kidney  from  slipping 
out  of  the  grooves  of  the  back  alongside  the 
spinal  column.  This  is  very  effective,  and  many 
Surgeons  employ  this  method  solely,  mean- 
while building  up  the  patient  to  add  needed  fat 
and  strength. 

(b)  Radical  Treatment  is  by  operation  in  which  a 

cut  is  made  through  the  muscles  of  the  back 
exposing  the  organ ;  stitches  are  then  taken 
through  its  covering  and  it  is  drawn  up  and 
stitched  into  place. 

The  operative  method  is  not  looked  upon  by  some 
Surgeons  with  as  much  favor  as  formerly,  for  experi- 
ence has  shown  that  even  a  perfect  "anchoring"  of  the 
organ  does  not  cure  the  symptoms,  the  latter  being  in 
the  vast  majority  of  cases  of  the  nervous,  subjective 
type. 

The  operation  is  not  severe,  the  scarring  is  slight 
and  the  period  abed  does  not  exceed  three  weeks,  and 
in  selected  cases  serves  admirably. 

SUMMARY :  A  very  frequent  condition,  especially  in  women, 
but  it  cannot  be  reasonably  said  to  follow  trauma  un- 
less a  severe  blow  be  inflicted  on  the  back  close  to  the 
kidney-region ;  then  the  signs  of  Shock  should  appear, 
with  probably  evidences  of  "Internal  Injury"  and  the 
onset  of  difficult  urination  and  blood  in  that  voided. 

If  in  a  woman  of  "long  and  lean"  build,  the  great 
probability  is  that  it  antedated  the  alleged  violence; 

ill 


this  is  made  reasonably  certain  if  she  conforms  to  the 
formula  given  above. 

Granting  its  occurrence  from  violence,  it  is  not  a 
dangerous  condition  and  is  frequently  amenable  to 
treatment  by  non-operative  means. 

It  is  usually  an  old  (perhaps  congenital)  condition 
discovered  in  a  nervous,  irritable  woman,  and  its  ex- 
istence was  unknown  because  no  careful  examina- 
tion had  ever  been  made  prior  to  the  time  that  some 
accident  called  attention  to  this  and  every  section  of 
the  anatomy. 


112 


XXI.     CONCUSSION     OF    THE     BRAIN. 


The  above  is  commonly  referred  to  as  "Concussion," 
although  any  organ  enclosed  in  a  bony  or  more  or  less 
unyielding  cavity  is  capable  of  undergoing  "Concus- 
sion ;"  for  example,  older  Surgeons  frequently  referred 
to  the  now  almost  obsolete  expression,  "Concussion  of 
the  Spine,"  and  occasionally  the  term  "Concussion  of 
the  Chest"  is  also  met  with. 

In  derivation,  "Concussion"  means  a  "shaking  up," 
and  a  technical  definition  of  the  Concussion  under  dis- 
cussion would  describe  the  condition  as  the  sudden 
jarring  impact  directly  upon  or  transmitted  to  the 
skull,  which  in  turn  is  transmitted  to  the  brain,  mani- 
festing itself  by  more  or  less  transitory  unconscious- 
ness, depression,  pallor  of  the  skin,  and  other  associated 
symptoms  allied  to  Shock  (see  article  on  latter). 

Synonymous  terms  are,  "Commotio  Cerebri,"  "Cere- 
bral Concussion,"  "Contusion  of  the  Brain,"  and 
"Cerebral  Contusion." 

CAUSES :  It  always  results  from  (a)  Direct,  or  (b)  Indirect 
Violence. 

Examples  of  Direct  Violence  would  be  a  blow  or  a 
fall  upon  the  skull,  with  or  without  damage  to  the 
soft  parts  (skin,  muscles,  tissues)  and  bones  of  the 
skull. 

If  it  follows  as  a  result  of  Indirect  Violence,  there 
has  been  a  heavy  fall  upon  the  feet  or  buttocks,  so  that 
the  impact  is  transmitted  to  the  unyielding  bony  cage 
of  the  skull;  injury  to  the  soft  parts  is  then  lacking 
in  the  region  of  the  skull,  and  if  the  latter  be  injured, 
a  fracture  of  the  base  (bottom)  of  the  skull  is  prob- 
ably present. 

SYMPTOMS:  These  depend  on  the  severity  of  the  violence, 
its  location  of  receipt  and  the  individual  tolerance. 

113 


In  degree,  Concussion  can  be 

(a)  Mild; 

(b)  Moderate; 

(c)  Severe. 

(a)  Mild  C.  causes  the  person  to  momentarily  "see 

stars,"  he  is  slightly  confused,  he  may  be 
temporarily  unconscious,  he  is  giddy,  is 
nauseated  and  may  vomit;  but  he  soon  re- 
sponds, and  in  a  short  lime  recovers  com- 
pletely, barring,  perhaps,  "a  bump  on  the 
head,"  some  pain,  soreness  and  dizziness  for 
a  few  days. 

(b)  Moderate  C.  is  an  aggravation  of  the  foregoing, 

the  unconsciousness  being  more  profound, 
the  vomiting  being  almost  invariable,  and 
aid  will  probably  be  required  in  reaching 
home.  His  after-effects  may  last  a  week  or 
two,  and  during  that  time  he  may  be  un- 
fitted for  mental  or  physical  stress,  but  the 
vast  majority  of  such  cases  completely  free 
themselves  of  symptoms  within  the  time 
named. 

(c)  Severe  C.  is  a  serious  condition,  and  its  severity 

is  proportionate  to  the  duration  of  the  coma 
and  the  profundity  of  the  associated  symp- 
toms of  collapse ;  such  a  person  remains  inert 
perhaps  for  days,  and  on  "coming  to"  has 
no  recollection  of  what  intervened  from  the 
instant  the  violence  was  inflicted,  and  for 
some  days  may  be  mentally  disturbed,  suf- 
fer from  memory-lapses,  and  may  even 
manifest  disturbances  closely  allied  to  af- 
fections of  the  brain  itself,  such  as  localized 
paralyses,  or  defects  of  the  special  senses. 

ANATOMY:     The   brain    is   enclosed   in    a  bony   cage,   the 
skull,  each  bone  of  which  is  mortised  into  that  adja- 

114 


cent,  the  junctions  being  free  enough  to  permit  some 
sliding  and  even  over-riding;  this  is  especially  true 
in  children. 

Surrounding  the  brain  is  a  layer  of  fluid  ("Cerebro- 
spinal fluid")  which  extends  down  into  the  spinal 
cord  through  a  large  hole  at  the  base  (bottom)  of  the 
skull,  and  hence  the  brain  is  well  protected  against 
violence  by  the  bony  cage  and  the  water-jacket-bumper 
of  fluid. 

The  brain  proper  is  covered  by  three  layers  of 
parchment-like  tissue  (the  chief  of  which  is  called  the 
"Dura  Mater")  and  does  not  come  directly  into  con- 
tact with  the  interior  of  the  skull  at  any  point,  and  in 
some  locations  is  an  inch  distant  from  the  bones. 

Running  in  this  protective  tissue,  and  over  and  in 
the  brain,  are  many  blood-vessels,  and  the  present  the- 
ory of  the  development  of  Concussion  is  that  some  of 
the  capillaries,  or  minute  blood-vessels,  are  torn  by 
the  transmitted  impact  so  that  temporary  abeyance  of 
function  ensues.  For  a  long  time  the  Concussion-the- 
ory was  that  of  "Molecular  Vibratory  Change"  in 
which  the  molecules  of  the  brain-substance  were  sup- 
posed to  be  set  in  motion  by  the  jarring,  with  the  con- 
sequent disturbance  of  function:  some  older  Surgeons 
still  hold  to  this  idea. 

Even  at  the  present  day,  it  is  generally  conceded  that 
there  are  few  if  any  structural  changes  accompanying 
this  condition,  and  in  cases  of  death  (from  associated 
injuries),  autopsy  fails  to  reveal  evidences  of  actual 
damage  even  when  microscopical  sections  are  repeat- 
edly examined ;  if  damage  has  been  done,  the  Concus- 
sion was  then  an  associate  of  Laceration  or  Contusion 
of  the  Brain,  with  or  without  fractured  skull. 

In  Concussion  of  this  type,  remnants  in  the  shape 
of  headache,  giddiness,  unsteadiness  of  gait  and  station, 
mental  and  physical  inaptitude,  "buzzing"  in  the  ears, 


115 


"spots"  before  the  eyes,  and  depression  are  frequently 
complained  of  for  weeks.  If  these  exist,  they  are  as- 
sociated with  corroborative  signs  indicative  of  illness, 
many  of  which  arc  visible  and  readily  provable;  if 
they  are  lacking,  the  subjective  allegations  may  be  re- 
sult of  an  attempt  to  deceive  for  a  purpose,  or  are  in- 
cidents of  a  neurasthenic  or  hysterical  type. 

There  are  usually  no  permanent  effects  from  Con- 
cussion ;  and  if  such  are  present,  there  has  probably 
been  allied  with  the  injury  some  damage  to  the  brain 
tissue,  and  in  such  an  event  there  are  invariable 
determinative  findings,  such  as  paralyzed  muscles, 
speech,  eye  or  ear  defects,  and  changes  in  the  reflexes. 

The  feature  of  Concussion  is  its  transitory  nature — 
if  the  symptoms  persist,  the  diagnosis  must  shift  to 
brain-injury. 

TREATMENT:  This  is  entirely  dependent  upon  the  symp- 
toms, but  it  can  be  summed  up  by  stating  that  abso- 
lute rest  is  given,  and  the  heart  is  stimulated  if  neces- 
sary; later,  individual  complaints  are  appropriately 
treated  in  the  usual  manner  by  drugs. 
Operative  interference  is  never  required. 

ALLIED  CONDITIONS:  The  milder  manifestations  of 
Concussion  closely  resemble  Syncope  ("fainting  fit"), 
Shock  and  Fright,  and  they  must  be  differentiated 
sharply ;  this  is  usually  possible  if  the  history  be  scru- 
tinized, and  if  there  be  no  direct  head-violence,  and  if 
the  transmitted  impact  be  light,  then  a  diagnosis  other 
than  Concussion  is  justifiable. 


116 


XXII.     NEURASTHENIA. 


Strictly  speaking,  the  derivation  of  the  word  means  weak 
nerves.  It  has  been  defined  by  a  well  known  writer  as  a 
functional  nervous  disorder,  characterized  by  excessive  ner- 
vous weakness  and  nervous  irritability,  so  that  the  patient  is 
exhausted  by  slight  causes  and  acts  morbidly  to  slight  irri- 
tations. 

As  it  is  generally  used,  it  is  synonymous  with  "nervous  pros- 
tration," "nervous  exhaustion,"  "railroad  spine,"  "railroad 
brain,"  "the  American  disease,"  and  what  has  been  jocularly 
called  "nervous  prosperity." 

It  is  among  the  most  widespread  of  nervous  diseases,  and  is 
regarded  by  most  competent  observers  as  a  combination  of  a 
lowered  nerve  vitality  plus  more  or  less  well  marked  hysteria ; 
others  regard  it  as  the  male  form  of  hysteria. 

Abeyance  of  will  power  ("Aboulia")  is  the  characteristic 
feature  of  the  ailment. 

CAUSES:  It  is  universally  admitted  that  as  a  basis  the  in- 
dividual must  show  an  excitable  nervous  organization, 
this  being  either  congenital  or  acquired. 

The  congenital  manifestations  may  be  directly  trans- 
mitted from  ancestors  or  the  result  of  physical  or  men- 
tal defects. 

The  acquired  causes  include  physical  or  mental 
strain  of  whatever  type;  commonest  of  these  being 
worry,  business  stress,  grief,  shock,  over-work ;  the 
abuse  of  stimulants,  tea  or  coffee ;  and  the  existence  of 
prior  or  coincident  disease,  such  as  rheumatism,  gout, 
syphilis,  stomach  trouble,  liver  trouble,  kidney  disease, 
heart  disease,  hardened  arteries ;  or,  in  fact  any  physi- 
cal or  mental  departure  from  the  normal. 

Certain  authors  have  gone  so  far  as  to  claim  that  in- 
jury produces  a  definite  form  of  neurasthenia  apply- 

117 


ing  to  it  the  term  "TRAUMATIC  NEURASTHEN- 
IA, "  synonyms  of  it  being  "Railroad  Spine"  or  Rail- 
road Brain,"  or  "Litigation  Neurasthenia."  However, 
the  concensus  among  the  authorities  is  that  traumatic 
neurasthenia  differs  in  its  manifestations  from  general 
neurasthenia  slightly,  if  at  all ;  any  difference  depend- 
ing largely  upon  the  physical  injury  inflicted. 

TYPES:  There  are  four  main  classes  of  neurasthenia  usually 
referred  to,  but  this  does  not  imply  that  one  division 
is  separated  from  the  other,  the  fact  being  that  the 
symptoms  are  so  multiple  and  varied  that  one  type 
blends  more  or  less  completely  with  the  other. 

These  four  types  may  be  said  to  be : 

i.  SPINAL  NEURASTHENIA:  that  form 
in  which  the  symptoms  are  referred  to  the 
spine  or  back; 

2.  CEREBRAL  NEURASTHENIA:  that 
form  in  which  most  of  the  symptoms  are  of 
the  mental  type ; 

3.  GASTRIC  NEURASTHENIA:   that  form 

in  which  "nervous  indigestion"  is  upper- 
most ; 

4.  CARDIAC      NEURASTHENIA:        that 

form  in  which  the  heart  is  more  or  less  dis- 
turbed, and  palpitation  is  the  principal 
element. 

Other  authors  add  to  these,  RENAL  NEU- 
RASTHENIA, meaning  by  this,  bladder 
and  kidney  irritation. 

There  is  also  a  form  sometimes  referred  to 
as  SEXUAL  NEURASTHENIA,  in  which 
the  sexual  functions  are  lowered,  perverted, 
or  abolished. 


118 


SYMPTOMS:    These   depend,    in    part,   as    to   which    of   the 
types  the  individual  may  present. 

SPINAL  NEURASTHENIA  is  probably  the  com- 
monest form ;  and  under  this  condition  the  main 
complaints  are:  Pain  in  the  back,  localized  or  diffuse 
tenderness  along  the  spine,  inability  to  bend  forward 
or  backward,  weakness  on  exertion,  inability  to  stand 
or  walk;  and,  occasionally,  shooting  pains  in  the  back, 
and  tremors  of  the  face,  fingers  or  tongue. 

If  this  type  be  present,  the  individual  will  usually  al- 
lege that  he  has  received  a  sprain,  or  a  wrench,  or  a 
contusion  of  the  back,  the  violence  being  inflicted 
directly  over  the  affected  part,  or  indirectly,  so  that 
an  impact  was  received  at  the  point  of  maximum  com- 
plaint, this  actually  being  the  lower  middle  (lumbar) 
portion  of  the  spine. 

Under  the  CEREBRAL  FORM,  the  chief  symptom 
may  be  said  to  be  headache,  this  usually  being  referred 
to  the  forehead,  or  the  nape  of  the  neck,  and  claimed  to 
be  of  a  peculiar  boring  nature,  oftentimes  giving  the 
sensation  as  if  a  lead  cap  or  helmet  were  placed  upon 
the  scalp. 

The  individual  will  also  claim  that  he  is  mentally 
inapt;  that  his  powers  of  concentration  are  lost;  that 
he  readily  fatigues  under  mental  stress;  that  he  is 
easily  depressed;  he  is  morose,  irritable,  introspective, 
imaginatory;  and  he  oftentimes  sums  it  up  by  saying: 
"I  cannot  think  or  use  my  mind." 

A  chief  symptom  under  this  form  is  insomnia;  this 
manifesting  itself  as  an  inability  to  fall  asleep,  or,  fail- 
ing this,  he  falls  asleep,  but  readily  awakens  and  paces 
the  floor  in  an  effort  to  again  fall  into  slumber.  Dreams 
and  nightmares  are  also  alleged. 

119 


Under  the  GASTRIC  OR  STOMACH  FORM,  it  is 
Usually  claimed  that  there  are  multiple  symptoms  of 
indigestion;  distress  before  and  after  eating;  gas  col- 
lects in  the  stomach;  the  tongue  is  fonl  and  coated; 
constipation  exists,  and  in  general  the  food  does  not 
assimilate  and  the  appetite  is  capricious. 

Under  the  CARDIAC  FORM,  palpitation  is  the 
main  element,  this  occurring  on  slight  physical  or  men- 
tal exertion,  especially  if  the  patient  be  suddenly 
startled  or  if  unusual  exertion  be  demanded.  Asso- 
ciated with  this  is  oftentimes  numbness  of  the  extre- 
mities, a  feeling  of  heat  or  cold  therein,  and  a  peculiar 
flushing  of  the  skin,  allied  to  blushing;  many  of  these 
individuals  have  what  is  technically  known  as  Demo- 
graphy (a  red  line  produced  on  the  skin  when  the  finger 
nail  is  drawn  across  it)  so  that  letters  may  be  written 
on  the  individual  as  if  in  "symbols  of  blood." 

If  the  SEXUAL  FORM  exists,  either  separately  or 
allied  with  any  or  all  of  the  above,  the  sufferer  will 
claim  that  the  sexual  power  is  lost ;  that  the  sexual  ap- 
paratus is  defective;  and  that  virility  is  abolished. 

Under  the  RENAL  FORM,  the  chief  manifestations 
are  irritability  of  the  bladder,  so  that  he  is  unable  to 
retain  his  urine  long  at  one  time ;  that  the  passage  of 
it  is  painful,  and  especially  that  he  has  to  get  up  at 
night  to  relieve  himself.  His  fears  will  be  especially 
marked  if  he  happens  to  void  his  urine  into  a  vessel 
and  observes  next  morning  that  sediment  is  present, 
and  he  immediately  jumps  to  the  conclusion  that  he 
has  an  incurable  kidney  or  bladder  affection. 

From  the  above  it  will  be  seen  that  the  SYMPTONS 
ARE   VERY   VARIED,   but    the   great   majority   of 

120 


these    cases    present    as    main    subjective    (invisible) 
symptoms : 

Headache ; 

Backache ; 

Palpitation  of  the  Heart; 

Mental   and   physical   inaptitude,   and   lack   of 

initiative ; 
Insomnia; 
Stomach  irritability. 

OF  OBJECTIVE  (visible)  symptoms,  there  may  be 
mentioned : 

Exaggeration  of  the  Reflexes,  especially  that  of  the 
knee; 

"Limitations  of  the  Visual  Field,"  by  which  is  meant 
a  symmetrical  dimming  of  vision  demonstrable  by  ap- 
propriate tests; 

Hypersensitiveness  of  the  skin,  so  that  when  the 
finger  is  drawn  across  it,  a  red  line  appears — technic- 
ally called  "Dermography"  or  "Dermographism" 
(meaning  skin-writing)  ; 

Rapidity  of  pulse  and  heart  fatigue,  most  apparent 
after  exertion; 

Increase  of  pulse  beats  when  pressure  is  made  over 
the  alleged  tender  spots — this  being  known  as  "Man- 
kopf's  Sign." 

The  appearance  is  oftentimes  characteristic  to  an 
experienced  observer;  but  the  apparently  good  phy- 
sique of  the  individual  occasionally  belies  actual  con- 
ditions. 

COURSE:  The  duration  is  variable,  and  depends  very  largely 
upon  the  individual's  nervous  and  physical  makeup, 
the  causes  underlying  the  condition,  and  those  produc- 
ing it,  but  especially  on  the  treatment  that  is  afforded. 

121 


If  he  be  of  unstable  nervous  or  physical  structure, 
the  duration  will  be  indefinite,  and  he  may  go  on  into 
a  state  that  is  sometimes  called  CHRONIC  NEURAS- 
THENIA, and  practically  never  regain  his  normal 
tone;  but,  on  the  contrary,  if  he  be  of  a  strong  and 
healthy  disposition,  and  if  he  be  treated  in  a  proper 
manner,  cure  is  as  nearly  certain  as  in  any  nervous 
disease.  He  may  recover  within  a  few  weeks,  or  he 
may  be  ill  for  many  years,  so  that  sometimes  no  de- 
finite statement  can  be  made  as  to  the  length  of  time 
the  ailment  will  exist. 

GENERAL  CONSIDERATIONS:  One  main  characteristic 
of  the  disease  is  that  the  idividual,  almost  invariably, 
recognizes  the  baselessness  of  his  ills,  but  he  claims  no 
inherent  power  to  relieve  or  control  them. 

The  subjective  or  personal  symptoms  are  always  in 
excess  of  those  visible  or  objective,  and  it  is  not  es- 
sential that  there  should  be  any  severe  injury  or  sick- 
ness in  order  that  the  disease  be  produced ;  in  fact,  it 
is  a  well  known  feature  that  the  sights  and  sounds  in- 
cident to  an  accident  are  oftentimes  a  greater  produc- 
ing cause  than  the  infliction  of  actual  physical  violence 
in  the  susceptible. 

A  further  point  is  that  the  neurasthenic  is  fond  of 
relating  his  ills  to  sympathizers,  and  at  each  repetition 
his  list  grows  longer  and  is,  perhaps,  added  to  by  the 
experience  of  the  sympathizer,  who  relates  a  case  in 
which  the  symptoms  varied  somewhat  from  those  just 
related ;  hence  the  vicious  circle  increases  as  if  by 
geometrical  progression. 

It  may  also  be  stated  that  there  is  no  definite  an- 
atomical basis  for  the  condition,  so  that  at  autopsy  no 
central  or  superficial  nervous  disturbance  can  be  found. 

It  was  first  described  by  Dr.  Beard,  of  New  York, 
and  for  a  long  time  was  not  regarded  by  foreigners  as 

122 


a  definite  disease,  and  was  laughingly  referred  to  by 
them  as  the  "American  sickness." 

It  has  been  aptly  called  the  disease  of  the  strenuous 
and  not  of  the  simple  life. 

It  has  been  said  to  be  the  result  of  bad  heredity  and 
foolish  living. 

Certain  of  these  individuals  get  a  fixed  idea  of  some 
mental  or  physical  impairment  and  self-hypnotize 
themselves  into  the  belief  that  this  functional  ailment 
has  an  organic  basis,  and  delude  themselves  into  be- 
lieving that  every  pain  and  ache  proceeds  from  this  as 
a  center.  This  sort  of  NEURASTHENIA  is  referred 
to  as  the  outcome  of  AUTO-SUGGESTION,  and  the 
imagination  in  such  a  case  sways  the  will  and  leads 
to  the  development  of  all  sorts  of  impossible  conditions. 
The  symptoms  in  every  case  are  very  real  to  the  in- 
dividual, but  have  no  constancy,  and  to-day  may  exist 
in  one  portion  of  the  body  and  to-morrow  in  another, 
none  of  them  having  any  palpable  existence,  nor  are 
all  capable  of  external  demonstration  by  any  means 
within  the  power  of  the  physician,  except  to  the  ex- 
tent noted. 

It  is  this  connection  that  the  element  of  MALIN- 
GERING enters,  and  it  is  oftentimes  a  difficult  matter 
to  draw  the  line  between  the  real  and  the  unreal. 

Likewise  HYPOCHONDRIASIS  (imaginatory  dis- 
ease) must  also  be  differentiated ;  and,  given  a  tend- 
ency to  exaggerate,  plus  a  disturbed  imagination,  then 
all  the  factors  for  multiple  symptoms  are  present. 

Here  enters  also  the  effect  of  litigation,  and  so  long 
as  an  individual  is  harrassed  by  the  narration  of  an  ac- 
cident in  his  preparation  for  a  jury  appearance,  to- 
gether with  the  worry  over  the  outcome,  then  just 
so  long  will  his  many  sided  ailments  be  on  the  increase 
and  remain  uppermost  in  his  mind ;  and  if  to  the  im- 
portunities of  his  attorney  be  added  the  technical  sug- 

123 


gestions  of  a  physician,  his  multiplicity  of  symptoms 
■will  be  surprising  and  often  disproportionate  to  his 
good  appearance. 

A  certain  class  of  physicians  even  go  so  far  as  to 
deny  the  reality  of  neurasthenia,  and  believe  that  al- 
legations of  this  sort  are  founded  solely  on  a  desire  to 
deceive,  and  class  all  such  sufferers  as  malingerers. 
This,  however,  is  regarded  as  an  extreme  view,  and  is 
not  well  borne  out  by  that  class  of  individuals  who 
genuinely  suffer. 

TREATMENT:  The  essential  rule  in  the  treatment  of  any 
disease  is  "Remove  the  Cause,"  and  in  no  ailment  is 
this  dictum  more  important.  Hence  the  keynote  in 
the  management  of  the  neurasthenic  is  Isolation,  and 
the  earlier  he  is  removed  from  the  zone  of  anxious 
"friends"  and  sympathizers,  the  earlier  and  more  com- 
plete will  be  his  recovery.  This  is  especially  import- 
ant where  litigation  is  in  view,  or  where  there  is  some 
object  to  be  gained  (vacation;  relief  from  irksome 
work,  etc.)  and  it  is  safe  surmise  that  no  case  will  re- 
cover under  home  surroundings  where  there  is  the  sug- 
gestion of  an  interested  family,  a  designing  Doctor  or 
a  "Contingent  Fee"  lawyer,  all  of  whom  are  rehearsing 
for  a  Jury  presentation. 

Having  removed  the  case  to  proper  quarters,  the  ob- 
ject is  to  divert  the  attention  from  self;  and  with  this 
in  view,  moderate  exercise  is  given,  a  new  occupation 
is  perhaps  advised,  and  the  physical  rather  than  the 
mental  side  is  occupied. 

In  some  cases,  the  "Rest  Cure"  is  used,  and  by  this 
is  meant  total  cessation  from  all  exertion,  absolute  rest 
with  an  attendant  to  aid  even  in  such  simple  acts  as 
turning  in  bed;  this  is  especially  potent  with  "highly 
strung"  women  and  is  antidotal  to  the  strenuous  career 
that  was  causative  of  the  "Nervous  Breakdown." 

124 


Electricity  and  Massage  also  have  a  place,  and  special 
forms  of  Baths  are  frequently  employed. 

Drugs  are  not  used  as  routine  measures,  and  the  best 
Physicians  have  long  ago  ceased  the  use  of  "Nerve 
Tonics"  or  "Bracers"  of  the  Bromide  order. 

Individual  symptoms  (like  weak-heart-action  and  in- 
somnia) are  treated  by  appropriate  remedies,  but  medi- 
cines are  of  little  avail  unless  the  environment  is  bet- 
tered. 


125 


XXIII.     AFFECTIONS    OF   THE    COCCYX. 


COCCYX  is  derived  from  a  Greek  word  meaning  a  Cuckoo, 
the  idea  being  that  its  triangular  shape  resembled  a 
cuckoo's  beak. 

ANATOMY: — it  is  made  up  of  four  small  segments  of  bone, 
the  upper  often  remaining  unattached  to  these  below 
until  late  in  life.     (See  Diagram.) 

It  is  a  rudimentary  segment  of  the  lowest  end  of  the 
spinal  column  and  represents  the  tail  of  lower  animals. 

It  is  about  3  inches  long,  iy2  inch  wide  and  ^  inch 
to  Y±  inch  thick. 

Above,  it  joins  the  broad  segment  of  the  6pinal  col- 


The  Coccyx. 

umn  known  as  the  SACRUM,  to  which  it  is  attached 
by  a  very  strong  ligament,  the  SACRO-COCCYGEAL 
LIGAMENT,  this  acting  as  a  hinge  permitting  con- 
siderable forward  and  backward  motion  of  the  Coccyx; 
and  under  forced  bending  by  a  finger  in  the  rectum,  it 
can  be  bent  forward  almost  to  a  right  angle  and  almost 
an  equal  distance  backward ;  hence,  it  is  very  motile 
and  is  made  so  by  Nature,  for  otherwise,  each  time  we 
sat  down  forcibly,  it  would  break  or  dislocate.  It  is 
also  designedly  movable  because  the  Rectum  lodges  in 
its  hollow,  and,  when  distended,  forces  the  Coccyx 
backward.  In  pregnancy,  also,  the  child  lies  "in  the 
hollow  of  the  Sacrum  and  Coccyx" ;  hence,  from  many 
standpoints  it  is  structurally  a  hinged  "flail  joint." 

126 


The  normal  axis  of  the  Coccyx  is  forward,  making  approx- 
imately an  angle  of  about  120  degrees  from  a  straight  line,  it 
and  the  Sacrum  being  hollow  (especially  in  women),  forming 
a  semi-circle. 

The  upper  part  is  the  broadest,  and  it  gradually  tapers,  so 
that  at  its  lowest  end  it  forms  a  pointed  surface  about  as  large 
as  the  tip  of  the  little  finger;  the  upper  segment  is  also  the 
longest  (about  an  inch),  the  other  three  segments  making  up 
the  remainder  almost  equally,  so  that  it  looks  not  unlike  an 
arrow-head. 

Late  in  life  (approximately  at  fifty)  the  motility  between  the 
Coccyx  and  the  Sacrum  in  part  disappears,  and  the  two  bones 
are  then  practically  one ;  this  change  in  the  character  of  tissue 
takes  place  at  this  time  in  many  other  joints  also. 

In  some  cases,  up  to  the  age  of  about  twenty,  there  is  more 
or  less  motion  between  each  of  the  four  respective  segments, 
the  second  and  third  segments  being  the  last  to  join ;  hence, 
before  the  age  of  full  growth,  injury  to  this  section  of  the 
Spinal  Column  is  exceedingly  rare,  because  the  cartilaginous 
element  predominates  over  the  bony. 

RELATION  TO  THE   SPINAL  CORD. 

The  main  trunk  of  the  SPINAL  CORD  (or  SPINAL  MAR- 
ROW) ends  at  the  first  Lumbar  Vertebra  ("small  of  back") 
approximately  ten  inches  above  the  beginning  of  the  COC- 
CYX, so  that  there  are  no  main  nerve  trunks  in  this  vicinity. 
The  Spinal  Cord,  from  the  above  named  terminal,  sends  there- 
after numerous  fine  nerve  filaments  that  are  spread  out  in  this 
region  in  a  manner  resembling  a  horse's  tail,  hence,  this 
portion  of  the  Spinal  Cord  is  known  as  the  CAUDA  EQUINA 
(horse's  tail). 

The  nerves  about  the  Coccyx  play  an  unimportant  part  in- 
asmuch as  their  main  function  is  to  supply  sensation  to  the 
skin  near  the  rectal  outlet;  thus  it  is  that  the  entire  Coccyx 
can  be  removed  without  leaving  any  material  defects,  and  in 
this  respect  it  resembles  the  Appendix,  another  rudimentary 
section. 

127 


AFFECTIONS: 

Being  structurally  a  bone  and  a  joint,  it  is  subject  to  the 
same  forms  of  violence  as  any  other  bone  or  joint,  but  because 
it  has  unusual  protection  from  the  fat-layered  thickest  muscles 
in  the  body  (those  of  the  buttocks)  it  is  affected  only  by  vio- 
e  strongly  adminstered  directly  in  its  vicinity,  and  it  is 
made  less  vulnerable  also  because  of  its  structural  motility.  In- 
accessibility to  violence  can  be  best  appreciated  by  the  state- 
ment that  only  a  portion  of  it  can  be  touched  by  the  tip  of  a 
fully  introduced  finger  into  the  rectum  or  vagina. 

Practically,  there  arc  but  three  abnormalities  of  surgical  oc- 
currence, and  hence  only  the  following  will  be  discussed: 
FRACTURE  OF  COCCYX ; 
DISLOCATION  OF  COCCYX; 
IRRITABLE  COCCYX. 


128 


FRACTURE   OF    COCCYX. 

This  is  a  rare  injury  and  occurs  usually  as  an  accompani- 
ment of  other  graver  injuries  involving  the  pelvic  bones  (side- 
walls  of  abdomen)  following  crushes  (such  as  being  run  over 
by  heavy  wheels,  or  jamming  between  cars). 

A  kick  between  the  buttocks,  or  a  heavy  fall  DIRECTLY 
upon  same,  or  an  impingement  astride  a  rail  or  raised  surface, 
could  cause  a  fracture;  but  by  INDIRECT  violence  (as  a  fall 
on  back  or  hips)  no  such  effect  can  be  produced. 

The  recent  edition  of  STIMSON  on  "FRACTURES  AND 
DISLOCATIONS"  (perhaps  the  best  recognized  authority 
in  this  country)  devotes  only  19  lines  to  the  subject  of  "Frac- 
tured Coccyx,"  and  says:  "...  There  is  but  little  definite 
knowledge  concerning  it.  .  .  ."  The  author  doubts  its  oc- 
currence except  in  old  people  where  the  motility  of  the  part 
has  disappeared. 

The  "AMERICAN  TEXT  BOOK  OF  SURGERY"  devotes 
two  lines  to  the  topic,  thus :  "Fracture  of  the  Coccyx,  which 
is  very  rare,  resembles  in  symptoms  and  treatment,  dislocation 
of  the  same  bone." 

There  are  a  few  recorded  cases  in  which  difficult  or  instru- 
mental pregnancies  are  said  to  have  resulted  in  a  fracture  of 
the  bone.  The  rarity  of  this  fracture  can  be  estimated  when 
it  is  stated  that  only  0.3%  of  all  sorts  of  fracture  involve  the 
Pelvis  (bones  forming  the  base  of  the  abdomen),  and  of  the 
five  pelvic  bones,  fracture  of  the  Coccyx  is  most  infrequent. 


129 


DISLOCATION    OF    COCCYX. 

This  is  more  common  than  fracture,  but  it  is  also  rare,  and 
occurs  only  as  a  result  of  the  same  forms  of  violence,  viz.,  se- 
vere direct  force  applied  to  the  part. 

The  "AMERICAN  TEXT  BOOK  OF  SURGERY  says: 
"Dislocation  of  the  Coccyx  is  a  rare  injury,  more  common 
in  women  than  in  men,  and  is  accompanied  by  symptoms  of 
pain,  disability  and  nervous  disturbance  that  are  present  also 
in  cases  where  there  is  no  dislocation  or  fracture ". 

The  bone  may  be  dislocated  forward,  backward  or  laterally. 

FORWARD  DISLOCATION  is  the  commonest,  and  speak- 
ing of  the  symptoms  of  same,  Stimson  says :  "The  pain 
at  the  moment  of  the  accident  is  so  severe  as  sometimes  to 
cause  the  patient  to  faint;  there  is  pain  in  defecation  (move- 
ment of  bowels)  and  frequent  calls  to  urinate.  The  pain  rad- 
iates down  the  thighs,  and  sometimes  over  the  trunk,  head  and 
arms ;  the  patient  is  unable  to  sit  up,  and  the  slightest  move- 
ment may  greatly  increase  the  suffering.  Coughing  and  sneez- 
ing, and  sometimes  even  every  act  of  respiration,  increases  the 
local  pain.  If  the  condition  remains  unrelieved  (a  week  to  a 
month),  the  general  health  surfers  seriously,  the  patient  be- 
comes feverish,  and  the  mind  dulled." 

BACKWARD  DISLOCATION  occurs  only  during  child- 
birth, or  as  an  accompaniment  of  fracture  of  adjacent  bones  of 
Pelvis. 

LATERAL  DISLOCATION  cannot  occur,  according  to 
many  Surgeons,  except  as  associated  with  injury  to  adjacent 
parts.  Stimson  says  only  one  case  of  this  sort  is  found  in  all 
surgical  literature,  and  it  was  caused  by  a  fall  astride  a  chair. 


130 


IRRITABLE    COCCYX. 

Under  this  heading  is  included  all  forms  of  Coccyx  irrita- 
tion, including  Fracture  or  Dislocation,  especially  COCCY- 
GODYNIA  (painful  Coccyx)  or  COCCYGITIS  (inflamma- 
tion of  Coccyx)  and  Neuralgic  Coccyx,  these  last  three 
being  practically  synonomous. 

COCCYGODYNIA 

This  is  nervous  manifestation  and  is  usually  an  incident  in  an 
hysterical  or  neurasthenic  person  and  is  especially  common  in 
women. 

It  may  be  caused  by: 

Neuralgia ; 

Rheumatism  (common)  ; 

Uterine  trouble; 

Rectal  trouble ; 

Bladder  trouble; 

Piles ; 

Rectal  fissures ; 

Trauma  (contusions,  fractures,  dislocations). 

SYMPTOMS  (of  all  Coccyx  affections)  : 

(i)  PAIN :  this  is  most  marked  by  pressure,  so  that  in  gen- 
uine COCCYGODYNIA,  the  individual  sits  down  and 
arises  with  great  care,  chooses  soft  seats  and  lowers 
into  a  seat  from  the  edge  of  the  buttocks.  Walking, 
especially  up  or  downstairs,  by  jarring  the  spine,  also 
causes  pain.  Movement  from  the  bowels  and  bladder 
is  painful,  as  is  any  strain  or  stress  causing  pressure 
upon  the  part. 

(2)  SWELLING  AND  DISCOLORATION  (due  to  con- 
tusion) is  found  in  cases  caused  by  trauma;  this  us- 
ually disappears  in  from  five  to  fifteen  days. 

(3)  NEURASTHENIC  signs  of  the  usual  subjective  kind, 
especially  claim  as  to  pain  in  lower  back,  weakness  on 
muscular  effort  and  irritability  of  rectum  and  bladder. 

IN  THE  VAST  MAJORITY  OF  CASES,  COCCYGOD- 

131 


YNIA  (in  the  absence  of  an  unrelieved  fracture  or  disloca- 
tion) is  but  a  part  of  NEURASTHENIA,  HYSTERIA,  HY- 
POCHONDRIASIS, or  MALINGERING. 

THE  REFERENCE  HAND-BOOK  OF  MEDICAL 
SCIENCES  on  the  subject  of  "Coccygodynia,"  says:  "A 
favorable  prognosis  may  always  be  given  unless  the  pain 
should  be  dependent  upon  some  incurable  disease  elsewhere; 
otherwise,  with  proper  treatment,  complete  relief  can  be 
promised." 

The  fact  that  Coccygodynia  is  discussed  more  fully  in  text 
books  on  Nervous  Diseases  than  on  Surgery,  is  the  best  proof 
that  it  is  generally  looked  upon  as  a  nervous  manifestation, 
despite  its  occasional  surgical  origination. 

TREATMENT 

If  a  FRACTURE  OR  DISLOCATION,  the  bone  is  placed 
in  the  normal  position  and  kept  there  by  a  plug  placed  in  the 
rectum  or  by  any  other  of  the  numerous  methods  of  impro- 
vising a  retaining  splint. 

If  COCCYGODYNIA  exists,  the  treatment  is  that  of  Neur- 
asthenia. 

In  some  cases,  removal  of  the  entire  Coccyx  remedies  the 
pain ;  this  operation  is  simple  and  not  dangerous  and  the  re- 
mainins:  scar  is  small. 


132 


XXIV.     ELECTRIC     SHOCK. 


The  following  refers  solely  to  the  surgical  manifestations 
of  electric  current  having  origin  at  a  Power  House  and  dis- 
tributed by  charged  Rails  or  Wires ;  in  other  words,  the  ef- 
fects of  ELECTRIC  SHOCK  derived  from  Dynamos  used 
to  distribute  motive  power. 

DEFINITION:  By  "Electric  Shock"  is  meant  the  effect  pro- 
duced by  the  passage  of  an  electric  current  through 
the  body,  this  manifesting  itself  by  visible  ("ob- 
jective") or  invisible  ("subjective")  symptoms. 
MODES  OF  RECEIPT:  Electric  Shock  can  be  applied  to 
the  body  by  contact  with : 

i.     Charged  Wires  or  Rails; 

2.  Metal  Conductors  of  current; 

3.  Flashes  or  Sparks. 
DETERMINING  FACTORS:    The  effects  of  Electric  Shock 

are  generally  dependent  upon  the  following: 

1.  The  Individual;  an  excitable  person  is  gen- 

erally more  affected  than  one  of  stolid 
type ;  women  are  generally  more  affect- 
ed than  men;  the  alcoholic  more  than 
the  temperate;  the  aged  more  than  the 
young;  the  weak  more  than  the  strong; 

2.  Strength  of  Current ;  the  stronger  it  is  the 

greater  its  effect; 

3.  Method  of  Contact;  the  more  imperfect  and 

nearer  together,  the  less  the  effect.  For 
example,  contact  at  the  top  of  head  and 
also  at  soles  of  feet  will  transmit  the 
current  through  the  intervening  portions 
more  perfectly  than  if  the  contacts  were 
closer  together; 

4.  Duration  of  Contact ;  the  longer  the  current 

is  applied,  the  greater  its  effect; 

5.  Clothing;  if  rubbers  are  worn,  or  other  in- 

133 


sulating  material  is  close  to  the  place  of 

contact,  the  effect  is  less  marked  than  if 

an  unbroken  path  of  conduction  existed. 

There  is  no  one  portion  of  the  body  that  transmits 

electrical  charges  better  than  another,  so  that  contact 

on  the  head  does  not  necessarily  mean  more  damage 

than  if  contact  had  been  made  on  the  hand;  this  does 

not  imply  that  the  various  structures  are  equally  re- 

sistent  to  Electrical  Shock,  for  it  is  well  known  that 

the  Heart  and   Nervous  System  are  more  responsive 

to  electrical  stimulation  than  other  portions,  hence  it 

is  that  in  diseases  common  to  these  parts,  electricity 

is  frequently  made  an  adjunct  of  treatment. 

ELECTRICAL  TERMS: 

i.     VOLTS  are  units  of  Tension    (pressure). 

2.  AMPERES  are  units  of  Strength. 

3.  OHMS  are  units  of  Resistance. 

For  all  practical  purposes,  the  VOLT  will  be  the 
measure  mentioned,  inasmuch  as  "Voltage"  is  the 
quoted  standard  in  the  vast  majority  of  instances. 

AVERAGE  ELECTRICAL  CAPACITY: 

1,300  to  2,000  Volts  are  used  in  Electrocutions; 
550  to  575  Volts  are  used  in  Channel  Rail  and 

Overhead  Trolley  Systems: 
100  to  225  Volts  are  used  in  Electric  Lighting 

(Edison)  Systems; 
200  to  500  Volts  are  usually  not  dangerous. 
There  are  special  differences  as  to  electrical  effects 
depending  upon  the  factors  mentioned  under  the  para- 
graph, "Determining  Factors,"  and  also  as  to  the 
technical  amount  of  the  current  and  the  manner  of  its 
transmission.  For  example,  the  Amperage  is  impor- 
tant; only  7  or  8  Amperes  are  used  at  electrocutions. 
Essential  differences  also  exist  as  to  whether  or  not 
the  current  is  of  the  "Direct"    (continuous)   or  "Al- 

134 


ternating"  type ;  the  higher  the  frequency,  the  greater 
the  current  which  can  be  delivered  without  harmful 
effects. 

EFFECTS  OF  ELECTRICAL  SHOCK:     The    passage    of 
electricity  into  the  body  may  act  in  two  ways: 
i.     Externally,  or  Locally ; 
2.     Internally,  or  Systemically. 
External  Manifestations  are  in  the  form  of  Burns  of 
varying  extent  at  the  place  of  entrance  or  exit  of  cur- 
rent, and  these  may  be  of  three  degrees: 

ist.     Degree  Burns  show  as  mere  red  marks 

on  the  skin ; 
2d.      Degree  Burns  are  deeper  than  the  above 

and  show  as  raised  blisters  (Blebs)  ; 
3d.     Degree  Burns  cause  definite  destruction 
of  tissue  in  the  form  of  ulceration  or 
scarring  (Eschars). 
The  depth  or  degree  of  the  burn  is  not  always  an 
indication  of  the  severity  of  the  electric  shock,  but  if 
the   contact  has  been  with   a   charged   metallic   sub- 
stance  (as  a  wire  or  rail)   it  is  reasonable  to  expect 
some  external  evidences  to  mark  the  place  of  entrance 
and  exit  of  the  current. 

Internal  Manifestations  are  in  the  form  of  effects 
upon  the  central  or  superficial  nervous  system,  or 
upon  the  heart,  plus  symptoms  referable  to  the  direct 
effect  upon  the  tissue  the  electrical  energy  may  have 
been  centered  upon. 

In  a  general  way,  the  internal  effects  of  electricity 
are  those  of  Neurasthenia  and  Hysteria,  or  both ;  there 
are  no  special  physical  changes  produced  by  electricity 
that  are  common  to  it  alone,  and  when  nervous  ef- 
fects follow,  they  are  of  the  ordinary  "Traumatic"  Neu- 
rasthenia or  Hysteria  type. 

It  has  been  alleged  that  deafness  and  blindness  oc- 
casionally result  because  of  electrical  contact,  but  in 

135 


the  absence  of  a  destructive  burn  of  the  damaged  part, 
such  effects  are  almost  invariably  Hysterical  in  na- 
ture; this  is  especially  true  if  the  contact  has  been  of 
the  "Flash"  variety  in  which  a  spark  or  flame,  rather 
than  the  current,  has  come  into  contact  with  the  in- 
volved site. 

INDIRECT  ELECTRICAL  CONTACT:  It  has  been  claimed 
that  electrical  effects  can  occur  when  the  body  is  im- 
pinged upon  by  a  flash  or  spark  or  flame,  the  results 
being  identical  with  those  due  to  actual  contact  with 
an  electrically  charged  substance. 

Aside  from  the  effect  of  an  Electrical  Spark,  the 
element  of  "Electric  Shock"  is  lacking  in  such  indirect 
methods  of  contact,  and  the  effects  are  those  of  fright, 
burns,  or  temporary  dazzling,  such  as  follow  the  sud- 
den appearance  of  any  unusually  bright  light. 

The  sudden  "Flash"  or  "Flame"  (such  as  appears 
through  slot-rails)  does  not  differ  as  to  causation  or 
effect  from  a  flame  produced  by  other  methods,  inas- 
much as  it  is  the  product  of  ignited  foreign  matter  in 
contact  with  charged  metal,  and  it  is  in  no  sense  "a 
shock  of  electricity."  In  experimental  work,  persons 
have  stood  over  slot-rails  from  which  such  "Flame" 
emanated,  and  no  effects  have  been  noted,  and  even 
a  piece  of  cheese-cloth  is  but  slightly  scorched  under 
such  conditions. 

POINTS  OF  CONTACT:  Electrical  effects  due  to  accidents 
on  our  System  are  claimed  to  occur  under  the  follow- 
ing circumstances: 

i.  Direct  Contact  with  electrically  charged 
materials;  as  for  example,  employees  in 
Power  Houses,  or  workers  about  Chan- 
nel-Rails or  overhead  wires.  In  such  in- 
stances, the  point  of  entrance  of  the  cur- 
rent is  generally  well  marked  by  decid- 

136 


ed  burns,  and,  less  frequently,  the  place 
of  exit  of  the  current  is  similarly  identi- 
fiable. 

The  effect  of  the  contact  is  modified 
by  the  factors  named  above,  chief  of 
which  are  the  strength  and  duration  of 
current  and  the  resistance  offered  by  in- 
sulation. 
2.  Indirect  Contact  with  charged  objects  at  a 
distance  from  an  electrical  source;  as 
for  example,  stepping  upon  a  charged 
metal  car-step,  touching  a  grab-handle 
or  a  trolley-pole. 

Under  such  conditions,  the  electrical 
effects  are  less  apt  to  be  marked  by  ex- 
ternal evidences  in  the  form  of  burns, 
and  the  manifestations  are  stated  to  be 
of  the  "pins  and  needles"  variety,  with 
the  usual  subjective  Hysterical  and  Neu- 
rasthenic signs  as  later  developments. 

It  is  not  infrequently  claimed  that  the 
"Shock"  of  such  a  contact  has  been  sud- 
den and  startling  enough  to  make  the 
person  lose  his  balance,  and  the  sus- 
tained injuries  are  then  said  to  be  elec- 
trical, plus  those  due  to  direct  violence ; 
if,  however,  such  a  condition  arises,  the 
duration  and  degree  of  the  contact  must 
be  very  slight,  for  otherwise  the  strength 
of  current  would  be  great  enough  to 
paralyze  motion  and  the  person  "could 
not  let  go,"  if,  for  example,  he  had 
gripped  the  handle  or  dash. 

The  manifestations  of  this  kind  of  elec- 
trical contact  are  dependent  upon  factors 
identical  with  those  named  above,  but 


137 


it  is  to  be  borne  in  mind  that  the  indi- 
vidual and  the  type  of  clothing  worn 
(rubbers,  gloves,  etc.)  and  the  site  of 
contact  play  a  very  important  part. 
3.  Flashes  or  Flames.  The  effects  of  these 
are  identical  with  burns  following  con- 
tact with  any  overheated  substance,  and 
the  physical  manifestations  differ  only 
because  subjective  nervous  symptoms 
are  allied  as  allegations. 

SUMMARY:     Electrical  effects  cause  either: 

1.  Burns; 

2.  Neurasthenia  or  Hysteria; 

3.  Malingering. 

If  the  contact  be  not  too  strong  or  too  prolonged, 
and  if  external  effects  are  lacking,  and  if  the  person 
can  be  up  and  about  after  the  receipt  of  the  "shock," 
the  effects  are  entirely  subjective  and  are  usually 
created  for  the  purpose  in  view. 

Electrical  energy  is  a  valuable  adjunct  in  the  treat- 
ment of  certain  ailments,  and  the  sudden  thrill  due 
to  the  passage  of  an  electrical  current  through  the 
system  has  tonic  properties  so  well  recognized  that  it 
has  become  a  standard  means  of  treatment,  especially 
in  nervous  affections ;  viewed  from  this  standpoint, 
the  effects  of  current  speedily  recovered  from  (so  far 
as  objective  signs  are  concerned)  is  often  salutary 
rather  than  harmful. 


138 


XXV.     X-RAYS. 


The  "X-RAYS"  were  discovered  by  Wilhelm  Conrad  Roent- 
gen, in  1895,  and  they  are  sometimes  referred  to  as  "Roentgen 
Rays"  or  "New  Rays." 

The  theory  of  their  existence  is  the  discovery  that  rays  of 
light  can  be  produced  by  the  passage  of  an  electrical  current 
of  small  volume  and  high  tension  through  a  vacuum  tube. 

APPARATUS:  For  the  application  of  the  Rays  there  is 
necessary : 

1.  Electric  "Current"  transmitted  via  Storage 

Batteries,  Static  Machine  or  Street  Sys- 
tem; 

2.  The    "X-Ray    Tube"    in    which    they    are 

produced  and  from  which  they  emanate ; 

3.  The  "Fluoroscope,"  or  shadow  box,  through 

which  the  observer  gazes. 
Accessory  to  the  above,  or  as  modifications,  are: 

4.  The  "Induction  Coil"  to  be  used  with  Bat- 

tery or  Street  current; 

5.  The  "Vibrator"  or  "Interrupter"  to  quickly 

"make  and  break"  the  current; 

6.  The  "Rheostat"  to  temper  the  force  of  the 

current. 

ELECTRIC  CURRENT  derived  from  Storage  Batteries  or 
Street  wires  needs  no  comment.  That  derived  from 
a  STATIC  MACHINE  is  less  reliable  and  hence  less 
used;  if  employed,  the  machine  must  be  large,  having 
over  a  dozen  plates  (generally  glass  or  mica)  of  a 
diameter  approximating  three  feet,  being  operated  by 
a  small  motor  or  by  hand. 

X-RAY  TUBES  are  thin  glass  vacuums  usually  globular 
(about  the  size  of  a  grape  fruit)  with  pipe-like  pro- 
jections at  each  end  (about  three  inches  long),  to  which 
the  current-wires  are  attached,  respectively,  to  a  pos- 

139 


itive  ("Anode")  and  a  negative  ("Cathode")  pole. 
Within  the  tubes  is  a  concave  disc  of  platinum  on  which 
the  RAYS  bombard  to  be  reflected  by  a  small  mirror 
to  one-half  of  the  tube  so  that  all  the  lumination  can 
there  be  centered.  In  operation,  the  interior  of  the 
tube  is  filled  with  a  yellowish  green  light  and  the 
surrounding  air  is  permeated  by  a  characteristic  odor 
(ether). 

FLUOROSCOPES  are  generally  oblong  wooden  boxes  (usu- 
ally about  12x10  inches),  painted  black.  The  open 
end  is  for  the  observer's  head ;  the  sides  are  very  firmly 
sealed.  The  closed  end  has  a  removable  slide,  one 
surface  of  which  is  covered  by  a  substance  that  is 
fluoroscent  to  the  RAYS,  this  usually  being  a  CYAN- 
IDE of  BARIUM  and  PLATINUM.  The  RAYS 
themselves  are  invisible,  and  they  become  of  value 
only  by  virtue  of  causing  fluoroscence  in  other  ma- 
terials, such  as  the  above. 

SURGICAL  USES: 

i.     Examination  of  fractures; 

2.  Location  of  solid  foreign  bodies   (bullets, 

swallowed  coins,  etc.)  ; 

3.  Outlining   solid     organs     (heart,    kidneys, 

etc.)  ; 

4.  Treatment  of    certain    superficial    tumors, 

and  skin  diseases. 
It  is  to  be  carefully  noted  that  the  fluoroscent  rays 
show  as  silhouettes  only  and  are  in  the  truest  sense 
shadow  pictures;  hence  they  fail  fully  to  illuminate 
the  soft  parts,  such  as  the  skin,  thin  muscles,  bony 
covering  (Periosteum)  or  in  fact  any  tissue  that  offers 
no  obstacle  to  their  passage.  Some  manipulators  have 
been  able  to  obtain  outlines  of  the  more  delicate  tis- 
sues, but  the  majority  of  operators  are  capable  of  im- 
aging only  the  denser  objects. 

140 


TERMS:  FLUOROSCOPIC  EXAMINATION  is  where  the 
object  to  be  examined  (as  a  fracture)  is  interposed  be- 
tween the  tube  and  the  Fluoroscope,  the  closed  end 
of  the  latter  being  placed  on  or  close  to  the  examined 
portion,  and  by  regulating  the  strength  of  the  current, 
the  firmer  tissues  (as  bone)  are  outlined.  If  there  is 
any  fissure  or  loss  of  continuity  of  the  examined 
parts,  the  Rays  penetrate  it  and  a  bright  or  light  ap- 
pearance contrasts  with  the  surrounding  shadow;  or 
if  there  be  any  irregularity  (as  callus,  or  a  growth), 
the  abnormality  is  also  appreciable. 

This  sort  of  examination  is  valuable  in  early  frac- 
tures to  determine  the  amount  of  separation  between 
broken  bones,  the  overlapping  of  same;  or  after  "set- 
ting," whether  or  not  the  line  of  junction  is  good ;  and 
after  healing,  the  amount  of  callus  and  the  restoration 
of  outline. 

Obviously,  its  value  depends  entirely  upon  the  skill 
of  the  observer  and  his  willingness  to  interpret  what 
he  has  seen.  It  is  capable  of  purposeful  misinterpre- 
tation unless  the  precautions  named  below  are  com- 
plied with. 

RADIOGRAPHIC  EXAMINATION  receives  its 
name  from  the  derivation  of  the  first  word,  which 
means  "Ray-writing;"  it  is  also  sometimes  called 
SKIAGRAPHIC  EXAMINATION,  meaning  "Shad- 
ow-writing." 

Each  of  the  above  refers  to  the  photographed  X-Ray 
image  made  on  an  ordinary  (but  specially  prepared) 
sensitized  photograph  glass-plate;  hence  we  have  the 
equivalent  terms: 

i.     RADIOGRAPH; 

2.  SKIAGRAPH; 

3.  ROENTGENOGRAPH. 

METHOD  OF  EMPLOYMENT:   Whether  the  examination 
is  to  be  Fluoroscopic  or  Radiographic,  the  principles 

141 


involved  in  the  reproduction  of  any  image  are  to  be 
observed,  but  because  the  object  viewed  is  portrayed 
as  a  shadow,  and  because  only  the  denser  outlines  are 
visible,  extreme  care  must  be  taken  not  to  distort  the 
part  inspected  or  photographed. 

Inasmuch  as  FLUOROSCOPIC  examinations  are 
based  entirely  on  the  skill  and  honesty  of  the  observer, 
comment  is  unnecessary. 

For  the  absolute  correctness  of  a  RADIOGRAPH 
it  is  essential  that  the  following  be  complied  with, 
taking  as  an  example  a  fracture  of  both  bones  of  the 
leg: 

i.     Apparatus  must  be  in  good  order,  and  the 
examiner  must  be  familiar  with  it; 

2.  Photos  must  be  made  of  the  sound  as  well 

as  of  the  unsound  limb ; 

3.  Photos  must  be  made  in  both  axes  of  each 

limb   (from  before  back,  and  from  side 
to  side)  ; 

4.  In  each  of  the  four  photos,  the  X-Ray  tube, 

the  limb  and  the  plate  must  be  at  exactly 
the  same  distance,  or  focus; 

5.  The  plate  must  be  free  of  all  evidences  of 

manipulation     (over    or     underdevelop- 
ment, or  "touching  up"). 

6.  The  plate  should  be  previously  numbered 

or  otherwise  marked  to  avoid  mistake ; 

7.  All  dressing  should  be  removed,  as  most 

of  them   cast  shadows   easily   misinter- 
preted ; 

8.  The   operator   must    be    experienced,   and 

preferably  a  Surgeon. 

If  both  axes  of  an  injured  limb  be  not  "Rayed,"  it  is 

preferable  that  the  fore  and  aft  view  be  taken,  but  it 

should  not  be  regarded  as  of  any  value  unless  it  be 

accompanied  by  an  identical  view  of  the  normal  limb 

142 


taken  at  the  same  time,  by  the  same  operator  and 
absolutely  in  the  same  manner.  For  this  reason,  X- 
Ray  plates  are  now  made  large  enough  to  portray  both 
limbs  at  the  same  exposure,  but  it  is  imperative  that 
the  tube  be  centered  exactly  and  at  a  right  angle  to  the 
object. 

There  is  the  same  difference  in  taking  a  shadow- 
picture  of  a  limb  in  one  direction,  and  calling  it  stand- 
ard, as  there  is  in  photoing  an  individual  under  like 
conditions ;  a  profile  pose  does  not  often  look  like  a 
full  face. 

RADIOGRAPHS  can  be  so  manipulated  by  chang- 
ing the  distance  of  the  object  from  the  Tube,  or  by 
directing  the  Rays  slantingly  instead  of  vertically,  as 
to  distort  the  real  conditions  and  bring  into  relief  the 
desired  portion,  which  in  fact  may  be  a  natural  irregu- 
larity and  which  remains  undiscovered  because  the 
normal  side  is  not  Rayed  under  like  conditions. 

Dr.  L.  G.  Cole,  Radiographer  of  Roosevelt  Hospital, 
has  written  an  article  on  the  fallacies  of  the  X-Ray 
(in  our  Library)  and  in  order  to  demonstrate  his 
topic,  Radiographed  his  own  wrist  and  produced  a 
plate  which  indicated  the  callus  following  a  Colles' 
Fracture  (break  of  outer  forearm  bone  at  wrist),  but 
this  was  specious,  as  he  never  had  any  such  injury ; 
conversely,  he  so  manipulated  his  Tube,  Object  and 
Plate,  as  to  show  absence  of  callus  in  instances  where 
the  latter  was  visible  to  the  eye  and  could  be  felt  by 
the  examiner. 

For  purposes  of  deception,  it  would  be  very  easy 
for  an  operator  not  only  to  manipulate  his  apparatus 
and  object  as  above  stated,  but  equally  simple  to  inter- 
pose some  inpenetrable  object  (a  coin  or  small  piece 
of  metal)  in  the  desired  spot,  the  image  of  which  could 
be  attributed  to  an  alleged  irregularity  following  the 
injury. 


143 


PRINTS  FROM  RADIOGRAPHS:  If  the  plates  are  un- 
reliable and  worthy  of  scrutiny,  the  prints  from  same 
are  doubly  so,  as  the  opportunities  for  accidental  or 
purposeful  misconception  are  much  greater. 

Xo  PRINTED  RADIOGRAPH  should  he  accepted 
when  the  PLATE  can  be  viewed,  and  both  should  be 
excluded  unless  the  conditions  above  named  be  ful- 
filled. 

The  above  is  well  shown  by  reference  to  the  prints 
in  the  X-Ray  album  of  our  own  Library. 


144 


XXVI.     ABORTIONS     AND     MISCARRIAGES. 


From  a  technical  standpoint  there  are  three  terms  denoting 
interruption  of  the  normal  period  of  pregnancy,  and  these 
are  known  as : 

(a)  Abortions ; 

(b)  Miscarriages; 

(c)  Premature  Birth. 

ABORTION  is  the  interruption  of  pregnancy  prior 
to  the  end  of  the  third  month. 

MISCARRIAGE  is  the  interruption  of  pregnancy 
prior  to  the  end  of  the  seventh  month. 

PREMATURE  BIRTH  is  the  interruption  of  preg- 
nancy prior  to  the  end  of  the  tenth  month. 

Full  term  pregnancy  is  280  days,  or  ten  lunar 
months,  which  is  equivalent  to  nine  calendar  months. 

TERMS:  An  Abortion  or  Miscarriage  can  be: 

(a)  Complete ; 

(b)  Incomplete ; 

(c)  Spontaneous; 

(d)  Induced; 

(e)  Concealed. 

COMPLETE  ABORTION  or  MISCARRIAGE  is 
the  expulsion  of  the  fetus  and  the  intact,  unseparated 
"membranes." 

INCOMPLETE  ABORTION  or  MISCARRIAGE 
is  the  expulsion  of  the  fetus,  the  "membranes"  (whole 
or  in  part)  remaining  in  the  uterus. 

SPONTANEOUS  ABORTION  or  MISCARRIAGE 
is  one  that  results  from  any  of  the  causes  named 
below,  except  such  as  may  be  induced  by  drugs  or  in- 
struments, with  or  without  criminal  intent. 

INDUCED  ABORTION  or  MISCARRIAGE  is 
one  that  results  from  drugs  or  instruments  and  in 
which  intent  is  the  basis. 

145 


CONCEALED  ABORTION  or  MISCARRIAGE  is 
one  in  which  the  fetus  dies  and  remains  for  a  time 
(days,  weeks  or  months)  in  the  uterus;  a  rare  form. 

Of  the  above,  the  "INCOMPLETE"  variety  is  the 
most  common. 

FREQUENCY:  An  exceedingly  common  condition,  but  re 
liable  statistics  are  obviously  hard  to  collect  because 
of  the  secrecy  involved,  and  also  because  pregnancy 
interrupted  within  the  first  eight  weeks  gives  symp- 
toms so  slight  as  to  pass  unnoticed,  or  at  most  the 
signs  are  ascribed  to  excessive  menstruation  (Edgar's 
"Obstetrics"). 

Of  10,000  cases  of  labor  collected  by  Edgar  (he  has 
written  one  of  the   latest   and  largest  books  on   the 
subject  of  "Obstetrics"  and  is  Professor  of  that  sub- 
ject in  Cornell  Medical  College),  it  appeared  that  635 
were  interrupted  pregnancies,  distributed  as  follows: 
242  were  Abortions  (before  fourth  month), 
175  were  Miscarriages  (before  eighth  month), 
218    were     Premature     Births     (before    tenth 
month). 
Or  in  other  words  there  was: 

1  Abortion  to  every  41.3  Labors; 
1   Miscarrage  to  every  57.1  Labors; 
1  Premature  Labor  to  every  45.8  Labors. 
The  above  means  that  there  was  either  an  Abortion, 
a  Miscarriage  or  a  Premature  Birth  once  in  every  15.7 
Labors. 

These  records,  based  on  10,000  cases,  are  accurate 
and  made  for  statistical  purposes  based  on  Dispensary 
or  Out-Door  patients  who  were  treated,  mainly,  in 
their  own  homes. 

King's  "Manual  of  Obstetrics"  says  that  "90  per 
cent,  of  children-bearing  women  abort  once  or  more 
during  their  lives",  and  by  this  is  meant  interruption 
of  pregnancy  at  any  stage. 

146 


Interrupted  Pregnancy  is  more  common  among 
those  who  have  borne  children  than  in  those  who  have 
not,  as  is  well  shown  by  quoting  Edgar's  figures 
based  on  the  same  series  of  10,000  cases : — 

Tot.  Int. 
No.  Preg.       Abort.  Misc.  Prem.  Preg.  Tot.  Full.     All. 

1st    29        22        71       122      2,009        2iI3I 

2d,  3d,  4th,  5th.  120  94  97  311  5,202  5,513 
Beyond  5th  . .  79  49  46  174  2,047  2,221 
Unknown    14         10  4        28  107  135 


Total   242       175       218      635       9,365       10,000 

There  are  certain  months  at  which  pregnancy  is 
most  likely  to  be  interrupted,  and  the  same  author 
gives  the  following  statistics,  based  on  635  cases : 

Third  month,  23.9  %  interrupted  before  "Full  Term." 

Fourth  "  1 1. 18  " 

Fifth  "  6.93  " 

Sixth  "  6.15  " 

Seventh  "  9.60  " 

Eighth  "  12.63  " 

Ninth  "  12.25  " 

Figures  for  the  first  and  second  month  are  un- 
quoted by  this  author  because  they  are  unreliable ;  one 
"skipped  period"  does  not  indicate  pregnancy. 

Some  women  have  interruption  of  pregnancy  so 
often  as  to  contract  what  is  called  the  "Abortion"  or 
"Miscarriage  Habit,"  and  Edgar  says  that  of  407  cases 
of  Abortion  or  Miscarriage,  34  per  cent,  had  previously 
had  one  or  more  similar  experiences. 

In  218  cases  of  Premature  Labor,  he  found  26  per 
cent,  who  had  heretofore  an  identical  occurrence. 

It  is  a  well-known  fact  that  repeated  miscarriages 
render  the  uterus  intolerant  of  subsequent  foetation, 
and  the  fetus  is  retained  at  each  subsequent  impreg- 

147 


nation  a  shorter  time;  for  this  reason,  the  duration  of 
pregnancy  generally  becomes  progressively  less  at  each 
successive  interruption,  so  that  instead  of  Miscar- 
riages, Abortions  are  substituted  because  of  the  in- 
creasing uterine  irritability,  and  finally  it  becomes  im- 
possible for  impregnation  to  occur;  this  of  course  im- 
plies that  the  causative  factors  are  unrelieved. 


APPEARANCE   OF 
MONTHS: 


FETUS  AT  END  OF   DIFFERENT 


Month. 

Length. 

Weight. 

1st 

1-3  inch. 

20  grains. 

2d 

1.5     " 

60 

3d 


3.6 


450 


General  Conformation. 

Indistinguishable    as   a    human    form. 

Size  of  a  pigeon's  or  hen's  egg. 
Features  and  limbs,  with  webbed 
fingers  and  toes  are  visible,  but 
sex   undetermined. 

Size  of  goose-egg.  Webbing  of 
digits  disappears.  Head  distin- 
guishable   from    chest.     Sex    fixed. 

Hair-like  covering  on  body.  Sex 
well  defined. 

Face  wrinkled  and  senile.  Head 
huge. 

Hair  thicker  on  head.  Fat  on 
body.  Can  live  for  a  few  days; 
some  cases  on  record  of  survival 
if   incubator    reared. 

Some    survive    with    great   care. 

Survive  with  care.  Nails  do  not 
project  beyond  finger  tips  (this  a 
test    at    this    stage). 

Survival    positive   with   care. 

Fully  formed;  nails  beyond  finger 
tips;    eyes    opened.      "The    infant." 

Technically  speaking,  the  terms  "OVUM"  and  "EM- 
BRYO" are  used  in  reference  to  development  prior  to 
the  fourth  month  (i.  e.,  the  "Abortion  period"),  and 
thereafter  the  term  FETUS  or  FOETUS  (meaning 
"Offspring")  is  employed. 

It  will  be  seen  from  the  above  that  the  human  form 
is  not  distinguishable  until  the  second  month,  and  that 
the  sex  is  not  determinable  until  the  third  month. 

Many  women  when  menstruating  have  the  discharge 
in  a  clotted  or  membraneous  form  in  a  size  often  equal- 


4th 

4-5     " 

1800 

6th 

8-10     " 

10-12  oz. 

6th 

11-13     " 

IMi  lbs. 

7th 

14-15     " 

2V*i      " 

8th 

15-16     " 

3%      " 

9th 

16-18     " 

5%      " 

10th 

18-20     " 

7          " 

148 


ling  an  embryo  of  the  first  or  second  month,  hence  an 
abortion  at  this  period  has  not  enlarged  the  uterus  to 
any  great  degree  and  the  symptoms  are  generally  no 
more  severe  than  at  the  menstrual  epoch.  For  this 
same  reason,  tears  or  lacerations  of  the  neck  of  the 
uterus  ("Cervix")  or  of  the  space  between  the  vagina 
and  rectum  ("Perineum")  are  impossible  at  this  period 
because  the  pregnancy  products  are  not  large  enough 
to  overdistend  the  parts  mentioned;  lacerations  and 
the  resulting  scars  do  not  usually  ensue  until  the  fetus 
has  reached  the  sixth  or  seventh  month,  hence  the 
finding  of  a  scar  in  the  Cervix  (neck  of  the  womb)  or 
Perineum  (fleshy  space  between  rectum  and  vagina) 
is  proof  positive  that  conception  to  the  period  named 
has  occurred  at  some  time  in  the  woman's  history, 
this  being  further  confirmed  by  the  appearance  of  the 
breasts.  However,  a  scar  of  the  cervix  alone  may  fol- 
low an  operation  for  the  scraping  of  the  interior  of 
womb  ("Curettage"),  with  or  without  previous  im- 
pregnation. 

After  the  seventh  month,  survival  of  the  fetus  can 
occur  with  great  care,  and  hence  the  term  "Viable 
Period"  is  applied  to  a  birth  at  this  stage. 

The  Board  of  Health  Statistics  do  not  require  re- 
ports of  Abortions  or  Miscarriages,  but  all  cases  be- 
yond seven  months  are  regarded  as  "Still  Births"  if 
born  dead,  and  are  reported  on  a  special  certificate ;  but 
if  life  be  present  for  even  a  short  time,  the  regular 
"Death  Certificate"  is  filed. 

CAUSES  OF  ABORTIONS  AND  MISCARRIAGES:  These 

are  usually  referred  to  as : 

(a)  Predisposing  Causes; 

(b)  Exciting  Causes. 

Predisposing  Causes:   These  may  refer  to  the  mother, 
father  or  child. 

149 


Maternal  Causes: 

Too  early,  late  or  frequent  pregnancies; 

Obesity;  Emaciation;  Constipation;  Excessive 
Vomiting; 

Marriage  of  Consanguinity; 

Fevers  and  illness,  such  as  Malaria  and  Ty- 
phoid; 

Certain  poisons  such  as  Alcohol,  Lead  and 
Arsenic ; 

Drugs  used  with  intent,  such  as  Ergot,  Cotton- 
root  or  Tansy; 

Syphilis  (manifest  or  hidden)  a  cardinal  factor; 

Kidney  trouble  very  potent;  also  disease  of 
heart  or  liver; 

Mental  shock,  such  as  fright,  worry,  grief,  etc. ; 

Anaemia  (poor  blood)  a  large  factor; 

Tuberculosis  and  infectious  diseases; 

Hard  or  overwork,  especially  if  implying  ab- 
dominal strain ; 

Any  set  of  causes  lowering  vitality; 

Local  conditions,  such  as  Uterine  or  other  pel- 
vic inflammation ; 

Displacements  of  womb,  especially  backward ; 

Criminal  or  intended,  by  instruments  or  elec- 
tricity; 

Trauma,  especially  violence  over  abdomen. 

Paternal  Causes: 

Disease,  such  as  venereal  trouble  or  alcohol- 
ism ; 

Syphilis,  exceedingly  important ; 

Extremes  of  age ; 

Debility  from  any  cause. 
Fetal  Causes: 

Malformation  of  ovum  or  its  membranes; 

Excess  or  decrease  of  "bag  of  waters ;" 

Too  long  or  too  short  a  "Cord." 

1.50 


Edgar  states  "...  Perhaps  the  most 
important  cause  is  previous  uterine  disease,  as 
Endometritis,  which  is  quite  common  .  .  ."  "En- 
dometritis" means  inflammation  of  the  lining  of  womb 
and  it  is  an  exceedingly  common  condition  usually 
manifesting  itself  by  a  more  or  less  profuse  whitish 
discharge  of  a  Leucorrhoea  type  ("The  Whites"),  and 
it  causes  interruption  of  pregnancy  because  it  has  in- 
flamed the  inside  of  womb  to  such  an  extent  that  the 
latter  contracts  and  expels  the  fetus  or  kills  it  by  the 
irritating  and  germ-containing  "catarrhal  discharge." 

TRAUMA  (injury)  as  a  causative  factor  is  often 
over-estimated,  and  in  the  absence  of  some  of  the 
above  predisposing  influences,  considerable  violence 
is  generally  necessary  before  pregnancy  is  terminated 
thereby.  Force  applied  to  the  region  of  the  enlarged 
uterus  is  the  most  productive  type  of  violence,  but  in 
a  susceptible  woman  (due  to  the  predisposing  factors 
mentioned,  or  having  previously  aborted  or  miscar- 
ried), the  amount  of  force  required  is  often  inconsid- 
erable, and  it  can  be  inflicted  on  almost  any  portion  of 
the  body,  the  element  of  Shock  often  being  as  im- 
portant as  the  actual  violence. 

Jewett,  in  his  "Practice  of  Obstetrics"  says :  Trauma- 
tism as  a  cause  of  abortion  must  always  be  accepted 
with  considerable  scepticism.  Pregnant  women  have 
been  known  to  sustain  the  most  severe  injuries  with- 
out aborting.  On  the  other  hand,  to  the  most  trifling 
accident,  such  as  a  misstep  or  a  simple  fall,  is  frequent- 
ly ascribed  by  the  laity  the  interruption  of  pregnancy." 
Of  the  great  number  of  possible  causes,  Edgar 
gives  the  six  following  as  the  most  common : 

i.     Diseased  lining  of  womb  ("Endometritis")  ; 

2.  Backward  displacement  of  womb,  with  or 

without  adhesions; 

3.  Syphilis; 


151 


4.  Kidney  trouble ; 

5.  Criminal  interference; 

6.  Low  attachment  of  Placenta  ("afterbirth"). 
It  has  been  said  that  a  healthy  ovum  in  a  healthy 

womb  is  dislodgable  only  by  instrumentation. 
SYMPTOMS  AND  DURATION :' These  in  part  depend  ox\ 
the  period  of  pregnancy,  but  in  a  general  way  the 
symptoms  during  the  first  three  months  ("Abortion 
Period")  are  much  like  those  of  an  excessive  men- 
struation. 

The  usual  combination  of  symptoms  can  be  stated 
thus  : 

1.  Abdominal  pain  or  tenderness;  after  third 

month  this  becomes  paroxysmal  and  is 
separated  by  intervals  and  approaches 
the  true  "Labor  Pain"  type; 

2.  Vaginal    bleeding;    at    first   this    is    slight, 

later  clots  are  expelled,  and  often  actual 
haemorrhage  occurs.  During  the  "Abor- 
tion Period"  (first  three  months)  the 
blood  loss  is  slight  because  the  entire 
contents  of  womb  are  generally  expelled 
in  a  "soft-shelled  egg''  manner; 

3.  Stomach   symptoms,   such   as   nausea    and 

vomiting; 

4.  Constitutional    signs,    such    as    weakness, 

perhaps  actual  fainting  ("Syncope"), 
headache  and  pallor. 

Whatever  be  the  initiating  cause,  it  is  usual  for  the 
symptoms  to  begin  soon  after  its  infliction ;  for  ex- 
ample, after  a  fall  or  other  trauma,  symptoms  are  usu- 
ally not  delayed  beyond  a  few  hours,  and  if  more  than 
a  day  intervenes,  it  is  not  unlikely  that  other  factors 
play  at  least  a  contributing  part. 

From  the  beginning  to  the  end  of  "Abortion  Symp- 
toms," 24  to  36  hours  usually  elapses.  (Edgar). 

152 


The  period  abed  varies  with  the  stage  of  preg- 
nancy, the  symptoms,  the  treatment,  and  the  indi- 
vidual, but,  generally  speaking,  a  week  or  ten  days  is 
sufficient ;  some  women  do  not  go  to  bed  at  all  nor  are 
their  regular  duties  interrupted. 

The  lying-in  period  at  full  term  is  generally  8  to  12 
days. 
TREATMENT:  A  "Complete"  Abortion  or  Miscarriage  Tone 
in  which  the  entire  contents  are  expelled)  requires  no 
treatment  aside  from  the  giving  of  drugs  (such  as 
Ergot),  and  douches  to  promote  uterine  contractions. 
If,  however,  the  membranes  are  not  expelled  com- 
pletely, they  become  a  menace  and  may  cause  blood- 
poisoning  ("Sepsis")  or  later  be  the  focus  for  the 
development  of  ovarian  or  other  pelvic  trouble. 

For  this  reason,  the  treatment  of  such  an  interrupt- 
ed pregnancy  designs  to  remove  the  retained  mem- 
branes, and  if  drugs  and  douches  fail  (as  is  frequent) 
resort  is  to  "Curettage"  or  "Curettement,"  this  mean- 
ing the  removal  of  what  remains  by  a  spoon-shaped 
small  instrument  introduced  into  the  uterus.  Fre- 
quently the  operation  can  be  performed  without  the 
use  of  an  anaesthetic,  and  it  is  by  no  means  severe 
and  is  the  commonest  operative  procedure  among  fe- 
males. 

Operative  treatment  of  this  type  for  such  Abortions 
or  Miscarriages  is  practised  by  the  best  class  of  phy- 
sicians, and  when  properly  performed,  the  uterine 
organs  are  rendered  healthy  and  the  interrupted  preg- 
nancy cannot  be  justly  blamed  for  the  development  of 
later  pelvic  trouble. 

Speaking  of  the  merits  of  this  treatment,  Edgar 
says:  ".  .  .  It  is  a  boon  to  the  working  classes 
after  instrumentation,  the  patient  may 
leave  her  bed  on  the  fifth  day  .  .  .  not  more  than 
half  an  ounce  of  blood  is  lost  by  instrumentation  be- 
fore the  fourth  month     .  ." 

153 


Improperly  treated  interrupted  pregnancies  may  re- 
sult in  the  retention  of  part  of  the  membranes  and 
these  may  become  infected  by  germs,  leading  to 
blood-poisoning  ("Sepsis")  or  to  the  involvement  of 
the  Ovaries  or  Tubes  (organs  lying  adjacent  to  the 
uterus  and  connected  with  it).  Such  retention  also 
prevents  the  return  of  the  uterus  to  the  normal  size 
(i.  e.,  a  large  pear),  and  the  condition  of  "Subinvolu- 
tion" ensues.  We  then  have  an  enlarged  and  over- 
weighted uterus  which  is  prone  to  fall  into  abnormal 
positions  because  of  its  own  "bogginess,"  and  hence 
displacements  occur,  these  being  generally  downward 
("Prolapsed  Uterus"  or  "Falling  of  Womb")  or  back- 
ward ("Retroversion  of  Uterus"). 

All  of  the  above  are  obviable  complications  if  due 
care  be  given  the  patient. 


154 


Y\TS 


~v 


COLUMBIA  UNIVERSITY  LIBRARIES  1  hsi. six 

RD  141  WI78  1906  C.1 

Street  railway  accidents'. 


2002128918 


